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CASE

A man aged 43 years came with complaints of chest pain. Chest feels heavy burden Ampek like overwritten. Pain is felt when the patient is doing the activity. pain lasted 20-30 minutes. Pain improved after the patient relax and stop its activity and after administration of balm on the front chest and back. Pain accompanied by nausea but no vomiting, no dizziness, no cough, no shortness of breath. HRMS: Since 2 days ago the patient had no pain. But in the morning before entering the hospital, the same pain came back along with shortness of breath. Pain is felt when the patient perform the activity. The pain lasts longer, 1 hour. Pain does not improve after the patient rested and giving balm. Patients feel anxious and uncomfortable, so that by the families of patients taken to hospitals Wirosaban. When Anamnesis: The patient complains of pain that is felt diminished, there was no shortness of breath, no nausea, no vomiting, no dizziness, no cough. Intake, eating and drinking well. CHAPTER normal, soft brown konsisitensi. Normal bladder, tends to many, patients do not feel Anyang-anyangan. The same complaint history there in 2008, but not routine treatment, no diabetes, and history of stroke. Mother patients also suffer from the same disease From the physical examination obtained vital sign temperature 36.5 oC, tension 140/80 mmHg, pulse 92 x / min regular, respiration 24 x / min, a second vesicular lung, heart sounds regular SI-S2, no noise audible systolic. From the investigation found ECG ST elevation: V1 - V5, LVH, pathological Q.

QUESTION
1. 2. 3. 4. Unfamiliar term? Why the patients chests feel pain when he got activity? After taking some rest and given some balm why does a patient pains feel better? In the patient medical record, a doctor does not find chest pains with difficulties to breathe, how can a patient gets chest pains with difficulties to breathe with longer duration and does not recover after some rest before patient gets into the hospital? 5. Is there any relationship between diabetes and stroke record with the patients recent disease? 6. Does family medical record contributes to patients recent disease? 7. What is the possible different diagnose in this patients case? 8. How can a doctor decide diagnose in the patients case? 9. What is the best treatment and management for the patient? 10. What is the possible complication that might exist if the patient does not get adequate treatment? 11. What is the patient prognosis? 12. What is the best way to prevent patient from recurring or even worst condition?

ANSWER
1. Chest pain : is discomfort or pain that you feel anywhere along the front of your body between your neck and upper abdomen.

Diabetes : is a group of metabolic diseases characterized by hipergliemia caused by defects of insulin secretion, impaired insulin or both 2. When someone do some activity, their heart need much oxygen to contract the muscle. Oxygen is brought by blood that flow through artery coronary. If there are some plaque that obstruct the artery, so blood supply to the miocardium decrease, indirectly oxygen cant reach the target (muscle). This condition is named ischemia. But, myocardium must be contract to supply many blood to all of the body (perifer), in the condition without oxygen (anaerobic), the metabolism of myocardium through glycolisis mechanism. There are many glucose that use in glycolisis, and the end product is lactat acid. Not only lactat acid, but many product that can make pain is released, like histamine or proteolitik enzym that didnt bring fastly by cononary blood flow that flush slowly. The high concentration from this product can stimulate nerve of pain in myocardium that bring impulse through sensory afferent nerve into central nervous system. 3. The presence of physical activity lead to chest pain in patients. We know that in doing physical activity, body requires energy. Energy derived from the metabolism of oxygen. So, while on the move, the body requires more oxygen to meet the needs of the network. If tissue hypoxia there was a shortage of oxygen supply network which if sustained will lead to cell death. Possibly, the initial pain attacks, the patient experienced only ischemia in heart muscle. At rest, the body does not require too much energy, so it can reduce oxygen demand. Thus, the work of the heart to pump blood throughout the body also decreases. If the cardiac work is minimized, ischemia in heart muscles due to lack of oxygen supply will be eased. While giving balm, serves to provide relaxation. Feeling relaxed will participate reduce stress, which will also play a role in dilating blood vessels. Dilation of blood vessels, will facilitate the flow of blood. Thus, tissue oxygen deprivation will again receive oxygen in sufficient quantities. 4. From the results of anamnesis found chest pain is felt like a heavy burden and pain overwritten arise while the patient is active. Pain is felt less than 30 minutes and improved after the break and smeared balm. From these data, possibly before being taken to hospital patients experienced angina pectoralis, which is chest pain caused by myocardial ischemia. Lack of oxygen causes a change from aerobic to anaerobic metabolism which would interfere with the function of metabolic, mechanical, and electrical. Pain caused by chemical and mechanical stimulation of sensory afferents end in the coronary vessel wall and myocardium which then would be perceived in the cerebral cortex. n this case, the pain experienced at the beginning of complaints probably due to blockages in coronary arteries is still less so after a quick break back patients can move again, but the longer the greater the blockage so that the heart tissue that should get more oxygen deficiency. The possibility of the original form of stable

further examination.) Possible pain got worse because 1. Plaque Rupture Atreosklerosis plaque rupture is considered the most important causes of unstable angina pectoris, which occurred suddenly subtotal or total occlusion of coronary vessels that previously had minimal narrowing. Atherosclerotic plaque consists of a nucleus that contains lots of fat and protective fibrotic tissue (fibrotic cap). An unstable plaque consists of a nucleus which contains fat and infiltration of macrophage cells. Usually the rupture occurs at the edge of the plaque adjacent to normal intima or in the shoulder of fat deposits. Sometimes cracks occur at the weakest wall plaque because of the protease enzyme produced by macrophages and the enzymatic weaken the wall plaque (fibrous cap). The occurrence of rupture causes activation, adhesion and platelet aggregation and activation causes the formation of thrombus. When thrombus closing blood vessels 100% will occur infarction with ST segment elevation, whereas if thrombi are not clog 100%, and only cause severe stenosis will occur unstable angina. 2. Thrombosis and Platelet Aggregation Platelet aggregation and thrombus formation is one of the bases of unstable angina. The occurrence of thrombosis after plaque disrupted due to interactions that occur between the fat, smooth muscle cells, macrophages, and collagen. The core of fat is the most important ingredient in the formation of platelet-rich thrombus, whereas smooth muscle cells and foam cells (foam cells) present in plaque associated with expression of tissue factor in unstable plaque. Once associated with blood, tissue factor interacts with factor VIIa to initiate the cascade of enzymatic reactions that result in the formation of thrombin and fibrin. As a reaction to the disruption of endothelial physiology, there pletelet aggregation and release the contents of granulation pletelet sparking a broader aggregation, vasoconstriction and thrombus formation. Systemic and inflammatory factors contribute to the changes incurred hemostase and coagulation and thrombosis play a role in starting the intermittent, in unstable angina. 3. Vasospasm The occurrence of vasoconstriction also has an important role in unstable angina. It is estimated that the endothelial dysfunction and vasoactive substances produced by platelets plays a role in changes in vascular tone and meenyebabkan spasm. Such localized spasm in angina printzmetal can also cause unstable angina. Spasm often occurs in an unstable plaque, and have a role in the formation of thrombus. 4. Plaque erosion without rupture The occurrence of constriction can also be caused by the proliferation and migration of smooth muscle in response to endothelial damage; a change in shape and lesions due to

the increase in smooth muscle cells can lead to narrowing of the vessels with complaints quickly and ischemia. 5. Diabetes mellitus (DM) has been known to be an important risk factor for coronary heart disease. It is estimated that nearly 200 million people worldwide have diabetes, either type 1 or type 2, but most suffer from type 2 diabetes. The number is expected to rise to 2-fold in 2005. Diabetes mellitus is a group of metabolic diseases characterized by hipergliemia caused by defects of insulin secretion, impaired insulin or both. DM is a chronic disorder and is associated with damage to various organs such as eyes, kidneys, nerves, heart and blood vessels. DM is classified into type 1 diabetes, type 2 diabetes, gestational diabetes and other types. Vascular complications due to diabetes were divided into macrovascular complications such as coronary heart disease, peripheral vascular disease and stroke, and microvascular complications such as retinopathy, nephropathy and neuropathy. The mechanism is thought to occur in DM so that the process occurs aterogenesis: - Abnormalities in the distribution of particles and lipoprotein apoprotein. - Glkosilasi and advanced glycation proteins in plasma and arterial walls. - Glycoxidation and oxidation - Procoagulant state - Insulin resistance and hyperinsulinemia - Proloferasi smooth muscle cells and the formation of the "from cell" due to hormonal stimulation, growth factor, and cytokine. If DM can be controlled by both course the incidence of complications is much smaller. In fact 50% of patients with DM had been diagnosed diabetic complications at the time the first time. Actually at this moment not only ensured that the DM that worsen the prognosis, but also proved that the conditions associated with increased pre diabetespun process of atherosclerosis by 2.4-fold increased risk for cardiovascular events in 15 years. Risk of failure jantungpun increases with blood sugar levels in those who are not in the diagnosis of DM. Peripheral vascular disease is also a common complication that accompany diabetes. In contrast with those without diabetes, peripheral vascular disease in patients with DM more virulent because of its involvement in the more distal vessels and is usually accompanied by neuropathy so as if asymptomatic so it will come too late and more who have to undergo amputation. Hypertension is more of 1.5 to 3 times found in people with diabetes compared to those without DM. Each increase of 5 mmHg systolic or diastolic blood pressure increases the risk of cardiovascular disease by 20-30% in patients with DM. Incidence of cardiovascular disease because diabetes is also associated with the passage of time, the longer the greater the DM diidap cardiovascular events.

Currently, DM is considered a CHD risk equivalent. Those suffering from diabetes even without a history of acute myocardial infarction have the same number of cardiovascular events with those without DM but had experienced myocardial infarction. Patients with DM have a risk of cardiovascular events in 10 years by 20%. Those who suffer from diabetes also have high mortality rates when experiencing cardiovascular events, they are dying more and more that get complications. Hence, for those who suffer from DM laksananya governance must be more aggressive, such as blood pressure control targets on them must be less than 130/80 mm Hg. Controlling cholesterol in patients with low and Dmpun must lebi aggressive LDL target of less than 100mg/dl. Treatment is given if cholesterol levels above 130 mmHg, but can also be given if LDLnya cholesterol levels less than 130 mg / dl. 6. Diabetes mellitus is an endocrine metabolic disease that can be genetically inherited. The risk of diabetes in children is greater if the parents have diabetes mellitus with a ratio of 1:10. And in this scenario the data obtained from the anamnesis that the mothers of patients suffering from diabetes mellitus, which is a risk factor for diabetes mellitus in these patients. And the emergence of patient complaints due to his diabetes, and exacerbated by strokenya history. 7. Differential Diagnosis 1. Acute Coronary Syndrome Apts (Unstable angina pectoris) - Pain chest at rest or mild activity, relieved by nitrates. - The ECG: T segment depression, T wave innervation, no wave Q. - Cardiac enzymes did not increase. # NSTEMI (Non ST Elevation Myocardial Infarction) - Chest pain is more severe and longer. - Not relieved by nitrates, need to be opium. - Results EKG: ST segment depression, T wave inversion - Cardiac enzymes increased at least 2 times the upper limit of normal value. # STEMI (ST Elevation Myocardial Infarction) - More severe and long (> 30 minutes), not relieved by nitrates, need to be opium. - Hyperacute T - T segment elevation - Q waves - T wave inversion - Increased minimum of 2 times the upper limit of normal value. 2. Acute myocardial infarction Anamnesis - Chest pain left - Felt like the press, sliced or in cekik and was spreading to the jaw, left hand, back and right chest to his right hand. - Chest pain is usually menentap> 20 minutes.

- Trigger factor before the attack, such as heavy physical activity, emotional stress - Sometimes complain shortness of breath Physical examination - Often seen pale - Nadi usually regular - Tachycardia - Tension rises Patients with AMI can have a picture of the different ECG: - Normal or non-specific ECG - ST-T wave changes of ST depression or inverted T (inverted) - EKG-specific, ie there are typical changes in the form of ST elevation, T wave changes, and the emergence of pathological Q waves. Check cardiac enzymes - Increase in the enzyme creatine kinase (CK) and creatinine kinase myocardial band (CKMB) 3. Angina pectoris is a discomfort in the chest as a result of an ischemic without myocardial infarction. Clinical classification of angina are basically useless for evaluate the mechanisms of ischemic. Although the pathogenesis of angina experienced change from year to year, but in general can be distinguished 3 types of angina: 1. Classical effort angina (angina classical) At necropsy usually obtained coronary atherosclerosis. In these circumstances, coronary obstruction does not always lead to such ischemic time break. However, when the blood flow needs exceed the amount that can be pass through the obstruction, but the ischemic and angina symptoms. Angina pectoris will arise in every activity that can increase the rate heart, blood pressure and cardiac inotropic atatus so O2 will need such increases in physical activity, cold air and eat a lot. 2. Variant angina (Prinzmetal angina) The form is rare and usually occur at rest, due to a decrease O2 supply blood to the myocardium of a sudden. Recent research shows obsruksi the dynamic result of coronary spasm in both arteries pain and normal. Increased coronary obstruction that does not settle this occurrence of angina during the break clearly accompanied by decreased blood flow coronary artery. 3. Unstable angina (unstable angina / ATS) Another term often used is preinfark angina, angina decubitus, Angina kresendo. Acute coronary insufficiency or mid coronary syndrome. This shape is a group who can change a situation like complaints increased progressively, formerly with unstable angina or angina the first time. Angina may occur at rest or work. In pathology is usually found in areas that have characteristics of myocardial ischemic own.

Clinical manifestations 1. Symptoms Obtained discomfort in the chest that is not always a pain, but can also be a feeling of fullness in the chest, depression, pain, choking or burning sensation. Pain can occur in the neck, throat, the area between the scapula bone, the jaw or arm. When angina occurs, patients can be crowded breath or weakness that disappeared after the angina disappeared. Can also occur palpitations, cold sweating, dizziness or nearly fainted. 2. Physical examination While angina may not show abnormalities. On auscultation may sound of galloping atrial or ventricular and systolic murmur at apex. Heart rate may drop, settle or increased in time angina attack. 3. ECG ECG should be done at the time of angina attacks, when a normal resting ECG, stress test should be done with a treadmill or bicycle ergometer. The purpose of the stress test is: e-USU Repository 2004 University of North Sumatra 3 - assess whether the chest pain comes from the heart or not. - Assessing the severity of diseases such as when abnormalities occur in blood vessels The main will give strong positive results. Electrocardiography ATS patients may be depressed ST segment, segment depression ST accompanied by T wave inversion, ST segment elevation, barriers to His bond branch and without changes in ST segment and T wave ECG Changes in ATS temporary and each can occur alone or sersamaan. These changes arise during angina attacks and return to normal picture or early after complaints of angina disappeared within 24 hours. If the changes are settled after 24 hours or Q wave evolution occurs, then referred to as IMA. 4. The enzyme LDH, CPK and CK-MB At ATS enzyme LDH and CPK levels can be normal or increased but not exceeds the value of 50% above normal. CK-MB is the most sensitive enzyme for myocardial muscle necrosis, but false positives can occur. This demonstrate the importance of enzyme levels in serial to get rid of the IMA. 8. Enforcement diagnosis: Anamnesis: Patients complaining of chest pain, chest pain feels like overwritten until heavy burden, pain is felt when the patient activity and pain lasts for 20-30 minutes, the chest pain can be caused by many factors could result because there is interference by the lower respiratory tract and may also be due to disorders of the heart, therefore the diagnosis can be established based on seriol ECG and enzyme tests. pain in because of

coronary heart disease can be divided into 3 types: atreriosklerotik heart disease caused by the aging process is characterized as the occurrence of reduced elasticity of intima thickening, accumulation of calcium, especially in large arteries, angina pectoris chest pain usually occurs during the 1-5 minutes and if more than 20 minutes possible miokar patient had an attack of acute infarction. CHAPTER normal, brown mushy consistency (the consistency of soft brown mungin in because of an increase in serum lipids. Uncontrolled diabetes stroke and hypertension could be a risk factor for AMI. Physical examination: Vital sign indicates 36.5 oC normal, 140/80 mmHg indicates tension Hipertesi stage 1, Nadi 92 x / min indicates a normal regular, respiration 24 x / min indicates a normal, indicating normal vesicular lung Second, the vesicular sound due to air through the ductus alveolar and alveoli, the sound heard throughout the lung field, his voice soft, low, inspiration is longer than the expiratory 3: 1, heard most clearly in the peripheral lung, inspiration> expiration, the heart signifies regular SI-S2 normal, no audible noise normal systolic sounds. Here the patient has hypertension, we have seen in the chronic high blood pressure will cause the gap and damage the endothelial lining of blood vessels. With the rupture of endothelial damage arising teradinya recurrent factors that promote inflammation cycle, accumulation of white blood cells and platelets and clot formation, called a thrombus, thrombus formed can become detached and cause embolism, damage also would interfere with the release of endothelial nitric oxide which is a vasodilator so that the blood vessels so vasoconstriction , this causes reduced blood flow and ischemia occur that cause pain. Investigations ECG: ST elevation: V1 - V5 indicates miocardium injury, injury to the possibility of describing the degree of cellular damage is more than just ischemia, and ST segment elevation is usually a sign of who can be counted on to find out about the occurrence of myocardial infarction has occurred and if the ST segment is usually returned to baseline within several hours. LVH: Left ventricular hypertrophy, left ventricular enlargement occurs. Q pathology: indicate there has been an irreversible myocardial cell death, because it is irreversible wave of Q tends to settle along the patient's life. Q wave formation occurs when a region in the myocardium dead, he had no electrical activity and no longer able to deliver electricity. As a result, all the heart's electrical force will be directed manjauhi infarct region. Therefore, the electrodes are located above the infarct region will record a negative deflection in. When viewed from the ECG investigation showed that the patients had acute myocardial infarction because there is ST elevation and pathologic Q visible presence indicates injury to the miocardim. In the anamnesis there was at IMA crushed chest pain such as heavy objects, radiating to the mandible or the left arm, accompanied by nausea, sweating, shortness

of breath. But on some of those who suffer from diabetes mellitus and the elderly usually do not show these symptoms. 9. TREATMENTS OF ACUTE MYOCARDIAL INFARCTION The main goals of ED medical therapy are rapid intravenous thrombolysis and/or rapid referral for PCI, optimizing oxygenation, decreasing cardiac workload, and controlling pain. ANTITHROMBOTIC AGENTS These agents prevent the formation of thrombus associated with myocardial infarction and inhibit platelet function by blocking cyclooxygenase and subsequent aggregation. Aspirin Administer as soon as possible. Inhibits cyclooxygenase, which produces thromboxane A2, a potent platelet activator. Early administration has been shown to reduce 35-d mortality rate by 23% compared with placebo. An added mortality benefit exists when used in combination with thrombolytics. Heparin Augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. Does not actively lyse preformed clot, but it is able to inhibit further thrombogenesis after thrombolysis. Heparin should be administered to patients undergoing PCI. Prevents reaccumulation of clot after spontaneous fibrinolysis. Benefit as adjunctive therapy for streptokinase not clear. VASODILATORS These agents oppose coronary artery spasm, which augments coronary blood flow and reduces cardiac work by decreasing preload and afterload. Nitroglycerin (Minitran, Nitrogard, Nitrol, Nitrolingual, Nitrostat, Nitro-Dur) Causes relaxation of vascular smooth muscle by stimulating intracellular cyclic guanosine monophosphate production. Result is decrease in blood pressure. BETA-ADRENERGIC AGENTS These agents inhibit chronotropic, inotropic, and vasodilatory responses to betaadrenergic stimulation and reduce blood pressure, which decreases myocardial oxygen demand. Metoprolol (Lopressor) Selective beta1-adrenergic receptor blocker that decreases automaticity of contractions. During IV administration, carefully monitor blood pressure, heart rate, and ECG. Goal of treatment is to reduce heart rate to 60-90 bpm. Esmolol (Brevibloc) Excellent drug for use in patients at risk for complications from beta-blockade, particularly those with reactive airway disease, mild-to-moderate LV dysfunction, and/or peripheral vascular disease. Short half-life of 8 min allows for titration to desired effect and quick discontinuation if needed. THROMBOLYTIC AGENTS

These agents prevent recurrent thrombus formation and rapid restoration of hemodynamic disturbances. Alteplase (Activase) Fibrin-specific agent with a brief half-life of 5 min. Adjunctive therapy with IV heparin is necessary to maintain patency of arteries recanalized by tPA, especially during the first 24-48 h. Heparin may be administered during tPA infusion. Streptokinase (Kabikinase, Streptase) Nonfibrin specific agent with a half-life of 23 min. Need for adjunctive therapy with heparin is controversial. Acts with plasminogen to convert plasminogen to plasmin. Plasmin degrades fibrin clots as well as fibrinogen and other plasma proteins. PLATELET AGGREGATION INHIBITORS These agents inhibit platelet aggregation and reduce mortality. Clopidogrel (Plavix) Selectively inhibits adenosine diphosphate (ADP) binding to platelet receptor and subsequent ADP-mediated activation of glycoprotein GPIIb/IIIa complex, thereby inhibiting platelet aggregation. Eptifibatide (Integrilin) Antagonist of the platelet glycoprotein (GP) IIb/IIIa receptor, which reversibly prevents von Willebrand factor, fibrinogen, and other adhesion ligands from binding to the GP IIb/IIIa receptor. End effect is the inhibition of platelet aggregation. Effects persist over duration of maintenance infusion and are reversed when infusion ends. ANALGESICS These agents reduce pain, which decreases sympathetic stress. Morphine sulfate (Duramorph, Astramorph, MS Contin) DOC for analgesia because of reliable and predictable effects, safety profile, and ease of reversibility with naloxone. Various IV doses are used; commonly titrated until desired effect obtained. ACE INHIBITORS These agents prevent conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, causing lowered aldosterone secretion. Captopril Has short half-life, which makes it important drug for initiation of ACE inhibitor therapy. Can be started at low dose and titrated upward as needed and as patient tolerates. 10. COMPLICATION OF ACUTE MYOCARARDIAL INFARCTION Arrhythmias / Heart block: Briefly, the LAD supplies most of the conduction system below the A-V node (the HisPurkinje system), while the RCA supplies most of the conduction system at and above the A-V node (including the S-A node and the A-V nodes themselves). Hypotension:

Hypotension may occur in various settings following acute MI. It is important to distinguish between the various causes of hypotension in the setting of acute MI because they are treated quite differently. MECHANICHAL COMPLICATIONS AFTER AMI Some of the potentially correctable mechanical complications of MI are described below, and their peak incidence is usually between 3 and 7 days following MI, when the myocardial tissue is softest, and most vulnerable to rupture. Acute mitral regurgitation: Acute MR may occur abruptly from rupture of a left ventricular papillary muscle resulting in a flail mitral leaflet, usually the posterior leaflet. This results in an abrupt decrease in forward cardiac output, leading to congestive heart failure and often to cardiogenic shock. Ventricular septal rupture: Acute ventricular septal rupture can occur usually several days following the acute infarction, due to softening of the necrotic portion of the septum. This can occur in both inferoposterior and in anterior myocardial infarction. A loud systolic ejection murmur usually occurs and results in an acute left-to-right shunt with congestive heart failure and usually cardiogenic shock. Left ventricular free wall rupture: Rupture of the left ventricular free wall is analogous to ventricular septal defect but occurs in the free wall of the left ventricle, usually resulting in abrupt cardiogenic shock OTHER COMPLICATIONS AFTER AMI Left ventricular aneurysm formation: Left ventricular apical aneurysm formation usually occurs following antero-apical myocardial infarction, after LAD occlusion. This weakening of the apical wall results in an outpouching or "dyskinesis" of the apex of the heart during systole. Right ventricular infarction: Right ventricular infarction occurs almost exclusively in the setting of right coronary artery occlusion. Hallmarks include elevation of the jugular venous pressure in the absence of pulmonary congestion. Hypotension often occurs in the absence of an elevated pulmonary capillary wedge pressure. Elevation of the ST segments may be present in the right precordial EKG leads. Pericarditis: Post infarction pericarditis usually begins several days after the infarct, due to an inflammatory exudate in the pericardium. Pericarditis pain is distinguishable from infarct pain because of its pleuritic nature, radiation to the left trapezius ridge, and the associated low-grade fever and pericardial friction rub. Cardiogenic shock Cardiogenic shock results when there is a marked reduction in forward cardiac output leading to hypotension, decreased organ perfusion, and at the same time elevated left ventricular filling pressures leading to congestive heart failure. This can be due to either

massive left ventricular infarction or can be the result of one of the mechanical complications described above. 11. The prognostic evaluation of the patient with an acute myocardial infarction is one of the most interesting unanswered problems. This is both because of its complexity and its implications in terms of secondary prevention. Several clinical studies have emphasized the reliability of the prognostic evaluation based on data collected during the first 24 hours. We therefore evaluated the prognostic relevance of 26 variables measured in the coronary care unit in 1914 patients admitted to our Unit as a result of acute myocardial infarction during the past 10 years. Twenty-four patients were lost to follow-up so that the evaluation refers to 1,890 patients, 1,506 of whom are males aged between 22 and 99 years (mean 58.1) and 384 are females aged between 29 and 88 years (mean 67.1); thus there is a greater prevalence of males. The sex-related difference in the age distribution is statistically significant. In-hospital mortality was analyzed using univariate and multivariate statistical methods (chi-squared test, multiple logistic regression analysis). The prognostic relevance of the considered variables in relation to the survival was analysed using the logrank test and using Cox's model. The variables associated with a greater risk of in-hospital death were found to be: age, presence of diabetes, anterior location of the infarct, arterial hypotension at admission, Killip class III and IV and the presence of ventricular tachyarrhithmias. In contrast, smokers had a lower in-hospital death risk. As to mortality during the followup, there was an association with age, female sex, pre-existent coronary disease, presence of high heart rate on admission, low peripheral tissue perfusion, x-ray documented pulmonary congestion, supraventricular tachiarrhythmias and intraventricular block. In contrast, the presence of obesity was associated with a reduced death risk during the follow-up. During the follow-up the most frequent cause of death was re-infarction, followed by sudden death, death from non-cardiac causes and heart failure. 12. Preventif for acute myocardial infarction prevention are: stop smoking, get used to living healthy, avoid fatty foods, weight loss. Controlling blood pressure, Lowers blood cholesterol levels with diet or with medication, Doing sport regularly.

SOURCES

http://www.brown.edu/Courses/Bio_281-cardio/cardio/handout4.htm http://emedicine.medscape.com/article/759321-treatment
http://emedicine.medscape.com/article/159383-overview http://repository.usu.ac.id/bitstream/123456789/3489/1/gizi-bahri8.pdf http://piofamul.com/wp-content/uploads/2010/09/pharmaceutical-care-penyakit-jantungkoroner.pdf http://www.fkumyecase.net/wiki/index.php?page=DIAGNOSIS+DAN+TERAPI+AKUT+MIOKARD+I NFARK+DENGAN+ST+ELEVASI

PLENARI DISCUSSION BLOK 16

TUTORIAL 6: Teuku Rezki Amriza 20080310129 Herlambang Surya Perkasa 20080310034 Hengki Exsar Aritama 20080310046 Nurul Azizatus Solehah 20080310050 Fergiawan Indra Prabowo 20080310074 Alindina Anjani 20080310078 Asti Haryani 20080310080 Verani Dwitasari 20080310081 Anita Setia Murdani 20080310110 Shorea Sylviana Puteri 20080310112 Yolanda Pitra Kusumadewi 20080310113 Galih Oktriasari Khoirunisa 20080310114 Aisha Yuswini A 20080310142 Dina Eka Bhintami 20080310159

The pathogenesis of Ath. remains unexplained,

but endothelial damage (and chlamydia infection?, see above) could be the primary event and the reaction to it may eventually lead to plaque formation (response to injury hypothesis; C). Plaques usually develop at sites of high mechanical stress (vessel bifurcation); in this way also hypertension becomes a risk factor. Among the reactions are an increased lipid uptake in the vessel wall as well as adhesion of monocytes and thrombocytes (C2,3), helped by HoCys. The monocytes penetrate into the intima and are transformed into macrophages (C4). These liberate reactive O2 radicals, especially the superoxide anion O2 (also helped by HoCys), which have a general damaging effect on endothelial cells and inactivate endothelium-formed NO on its way to the endothelium and the vascular musculature: NO + O2 ONOO (C5). This results in the loss of NO action, namely inhibition of platelet and monocyte adhesion to the endothelium as well as antiproliferative and vasodilating effects on the vascular musculature. The latter favor spasms (B and C7). Even in the early stages of Ath., O2 radicals modify by oxidation of those LDLs that have entered the endothelium (C7). Oxidized LDLs damage the endothelium and there induce the expression of adhesion molecules which allow vessel musculature to proliferate. Oxidation also results in altered binding of LDLs. They can no longer be recognized by ApoB 100 receptors (p. 246ff.), but rather by so-called scavenger receptors that are contained in large amounts within the macrophages. Consequently, these now phagocytize large amounts of LDLs and are transformed into sedentary foam cells (C9). Lipoprotein(a) can be oxidized and phagocytized in a similar fashion. Simultaneously, chemotactic factors of monocytes and thrombocytes trigger the migration of smooth muscle cells from the media into the intima (C6). Here they are stimulated to proliferate by PDGF and other growth-promoting factors (from macrophages, thrombocytes, damaged endothelium, and the muscle cells themselves). They, too, are transformed into foam cells by uptake of oxidized LDLs (C10). They form an extracellular matrix (collagen, elastin, proteoglycans) that also contributes to atheroma formation. The consequences of plaque deposition (B) are narrowing of the lumen that can lead to ischemia. Coronary heart disease ( p. 218ff.) as well as chronic occlusive arterial disease of the limbs with painful ischemia on exercise (intermittent claudication) are examples of this. Other consequences of plaque formation are stiffening of the vessel wall (calcification), thrombus formation that obstructs the residual lumen and can cause peripheral emboli (e.g., cerebral infarction, stroke) as well as bleeding into the plaques (additional narrowing by the haematoma) and the vessel wall. Thus weakened, the wall may be stretched (aneurysm; see below) and even rupture, with dangerous bleeding into the surrounding tissues, for example, from the aorta (see below) or cerebral vessels

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