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MYOCARDIAL INFARCTION
(STEMI)
PRESENTED BY : NUR RAISAH ULFAH- C 111 09382
SUPERVISED BY :Prof. dr. Peter Kabo, PhD, Sp. FK, Sp. JP (K),
FIHA, FASCC
Department of Cardiology and Vascular Medicine
Medical Faculty of Hasanuddin University
Makassar
2014
PATIENT IDENTITY
ID Number
: 651739
Name
: MR TP
Age
: 68 years old
Gender
: Male
Date of Admission
: November 14th 2014
HISTORY TAKING
Chief complaint : Chest pain
History of present illness
Occurred 3 weeks ago before entering the hospital and was
advancing in last couple of days so that patient have been referred
to the RSWS from torajas hospital cause there was no significant
improvement of symptoms.
At the beginning, Chest pain is suddenly felt in a substernal area,
pain is like crushed with heavy load. The pain wasnt radiated.
Duration of pain continuously more than 20 minutes with a cold
sweating, and not relieved by rest then increased by activity.
There are shortness of breath, nausea and vomiting, and so
complain about a heart burn. Patient didint have a fever and no
previous history of fever.
Defecation and urination : normal
HISTORY OF DISEASE
# Past Ilness history
No History of Hypertension
No History of DM
No History of high blood cholesterol
No History of previous heart disease
No History of epigastric pain
No History of asthma
# Family history
No family history of heart disease
# Personal history:
History of smoking one pack each day for more 30
years.
History of drinking alcohol, once in a week.
RISK FACTOR
Modifiable
- Drink alcohol
- Smoker
Non
Modifiable
- Gender : male (+)
- Age : 68th years old (+)
PHYSICAL EXAMINATION
General
status
Moderate
illness/well
nourished/compos
Vital
mentis
sign
REGIONAL STATUS
Head Examination
Eyes : anemia (-), icterus (-)
Lip
: cyanosis (-)
Neck : lymphadenopathy (-), JVP R+3 cmH2O
Thoracal Examination
Inspection
: symetric, normochest
Palpation
: mass (-), tenderness (-), VF R=L
Percussion
: sonor
Auscultation
: breath sound
:
bronchovesicular,
there are minimally ronchi in a basal lung,
wheezing -/-
REGIONAL STATUS
Heart Examination
Inspection : IC wasnt
visible
Palpation
: IC wasnt
palpable
Percussion : normal
heart size
Upper border: left 2nd ICS
Lower border
: left 5th
ICS
Right border : right
parasternalis line
Left border : left axillaris
anterior line
Auscultation : Regular of
I/II heart sound, murmur
(-)
Abdominal
Examination
Inspection : flat and
following breath
movement
Auscultation :
peristaltic sound (+) ,
normal
Palpation : liver and
spleen unpalpable
Percussion : tympani,
ascites (-)
Extremities
Oedema : pretibial (-),
dorsum pedis (-)
ELECTROCARDIOGRAPHY
(ECG)
INTERPRETATION
Rhythm : Sinus Rhythm
Heart rate : 84 bpm
Regularity : regularly
Axis
: Normoaxis, 30o
P wave : 0.08 sec
PR interval : 0.16 sec
QRS complex: duration 0.08 sec,
configuration q patologis at I, aVL
ST Segment: ST elevation at V2, V3, V4, V5
ST depresi at II, III, aVF
T wave : Normal
Conclusion : Sinus Rhythm, NormoAxis, Infark whole
anterior wall, Ischemic inferior, Old miocard infark high
lateral.
WBC
: 10,3 x 103
HGB
: 12,5 g/dl
HCT
: 36.8 %
RBC
: 4.04 x 106 /mm3
PLT : 437 x 103 /mm3
Cardiac enzyme
CK
: 84 u/L
CK MB : 6,7 u/L
Troponin T : 0,17u/L
Electrolyte
Sodium
:142 mmol/l
Potassium : 3,6 mmol/l
Chloride
: 111 mmol/l
Blood chemistry
Complete blood
LABORATORY EXAMINATION
GDS
: 105 mg/dl
SGOT
: 30 u/l
SGPT
: 56 u/l
Ureum
: 18
Creatinin : 1,0
PT
: 10,9
APTT
: 26,7
Total Cholesterol :
209mg/dl
HDL
: 31 mg/dl
LDL
: 143 mg/dl
Triglyseride : 162 mg/dl
Planning
EKG everyday
Echocardiography
Ro Thorax
Coronary
Angiography
WORKING DIAGNOSIS
Recent STEMI Anterior, KILLIP II
MANAGEMENT
Cardiac Diet
IVFD NaCl 0,9% loading 500 cc/24 hours
Anti Koagulan
Fondaparinux (Arixtra) 2,5 mg every 24 hours subcutan.
Isosorbid Dinitrat
Farsorbid 10 mg every 8 hours
Farsorbid 5 mg sublingual (pain attack)
Anti Platelet Aggregation
Loading Aspilet 160 mg, maintenance 80 mg every 24 hours
Loading Clopidogrel 300mg, maintenance 75 mg every 24 hours
Anti cholesterol
HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg)
Diuretik
Furosemide 40 mg every 12 hours intravena.
Laxative
Laxadin syrup 1 x 2 cth
Anti Anxietas
Alprazolam 0,5 mg every 24 hours in night.
DISCUSSION
ACUTE CORONARY
SYNDROME
ST SEGMENT ELEVATION MYOCARDIAL
INFARCTION
DEFINITION
Acute Coronary Syndrome (ACS) is a term for situations
where the blood supplied to the heart muscle is suddenly
blocked.
STEMI is a clinical syndrome defined by characteristic
symptoms of myocardial ischemia in association with
persistent electrocardiographic (ECG) ST elevation and
subsequent release of biomarkers of myocardial necrosis.
ANATOMY
CAD
Stable
Angin
a
Pectori
s
ACS
UAP
NSTE
MI
STEMI
PATHOPHYSIOLOGY
Inflamation
Plaque deposition
Stable plaque
Erosion
Thrombus
Thrombosis
Plaque rupture
Acute coronary syndrome:
Unstable angina
Myocardial infarction :
- Non Q waves
- Q waves
Retrostern
al or
substernal
chest pain
1
poin
t
Increased
by activity
or
emotion
1
poin
t
Relieved
by resting
or nitrate
SL
DIAGNOSIS OF ACS
At least 2 of the following:
1. Ischemic symptoms
2. Diagnostic ECG changes
3. Serum cardiac marker
elevations
ALGORITMA
Signs of myocardial
ischemia
ECG
ST segmen elevation
?
No
Lab
Biochemical cardiac
markers ?
No
Yes
Yes
STEMI
Acute Myocardial
Infarction
( Q-wave, non-Q wave )
NSTEMI
(No ST-Segment
Elevation
Myocardial Infarction)
Unstable Angina
INITIAL TREATMENT
Fixing the chest pain and fearness
Bed rest
Diet
O2 2-4 lpm via nasal prongs or face mask
Sublingual/oral/IV nitroglycerine
Antiplatelet: aspirin and clopidogrel
Morfin/petidine
Diazepam 2-5mg/8 hour
Initial Treatment
COMPLICATION
Arrythmia
Heart failure
Cardiogenic
shock
Rupture of
ventricle
septum/wall
Rupture of
chordae tendineae
Pericarditis
Tromboemboli
Prognosis
KILLIP CLASSIFICATION
Class
I
II
III
IV
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
60 80
2 points
3 points
DM/HTN or Angina
1 point
Exam
SBP < 100
3 points
HR > 100
2 points
Killip II-IV
2 points
Weight > 67 kg
1 point
Presentation
Anterior STE or LBBB
1 point
1 point
(0-14)
Total
Score
Risk of
Death in
30 days
0
1
2
3
4
5
6
7
8
9-14
0.8%
1.6%
2.2%
4.4%
7.3%
12.4%
16.1%
23.4%
26.8%
35.9%