Case Report

Medical Faculty of Hasanuddin University, Makassar 2013

Patient Identity
MR number Name Age Date administered : : : : 151821 Mr.SU 65 years old May 4th 2013

History Taking
Chief complaint: Chest pain It was felt since 9 hours before admitted to hospital. It was felt at the middle of chest, like pressed by a heavy things and radiated to his neck and left arm. It occured suddenly with duration more than 20 minutes, didnt trigerred by activity and didnt relieved by rest.

Shortness of breath (+), since 1 months ago, he can sleep with 12 pillow. DOE (+) , PND (-), Orthopnea (-)
Cough (-) Epigastric pain (+), Nausea (+), vomit (-), sweating (+) Defecation: normal Micturition: normal

Past Medical History

History of hypertension (+) since long time ago and took medicine regularly History of diabetes mellitus (+) since 10 years ago took medicine regularly History of dyslipidemia (-) History of smoking (-) History of hospitalization with stroke in 2000, 2006, and 2011 History of chest pain before (-) Family history (-)

Risk Factor
Modifiable : - Hypertension - Diabetes mellitus Non - Modifiable : - Gender (male) - Age : 65 years old - Stroke

Physical Examination
General status
Moderate illness/well nourished/conscious

Vital sign
BP : HR : RR : T : 130/90 mmHg 80 x/min 28x/min 36.70 C

Physical Examination
Regional status
Head Examination
- Eyes - Lip - Neck : Anemis -/-, icterus -/: Cyanosis (-) : JVP R +3 cmH2O

Chest Examination
- Inspection - Palpation - Percussion - Auscultation : Symmetric right = left, normochest : No mass, no tenderness : Sonor, lung-liver border in ICS VI right anterior : Breath sound : Bronchovesicular Additional sound : Ronchi +/+ basal, wheezing -/-

Cardiac Examination
- Inspection : Ictus cordis invisible - Palpation : Ictus cordis impalpable - Percussion : Right heart border in right parasternal line, left heart border midclavicle line ICS V - Auscultation : Regular of I/II heart sound, no murmur

Abdominal
- Inspection - Auscultation - Palpation - Percussion : flat, following breath movement : Peristaltic sound (+), normal : No mass, no tenderness, liver and spleen unpalpable : tymphani, ascites (-)

Extremities
- Oedema pretibial -/- Oedema dorsum pedis -/-

Electrocardiography (ECG)

Interpretation:
Rhythm : Sinus rhytm HR/QRS rate: 83 x/min Axis : Normal P wave: 0.08 sec PR interval: 0.2 sec QRS Complex: 0.16 sec ST segmen: ST elevasi V1-V4 T wave : T inverted pada lead II, III, AVF

Laboratory Findings
RESULT WBC RBC 8.440 [10^3/uL] 4.05 [10^6/uL] NORMAL 4.0-10.0 4.00-5.00

HGB
HCT

12.9 [g/dL]
37.8[%]

12.0-16.0
37.0-48.0

PLT
CK CK-MB TROPONIN-T CHOL TOT

271[10^3/uL]
760 [U/L] 52 [U/L] 0.27 288

150-400
L(<190), P(<167) <25 negative 150-200

RESULT LABORATORY FINDINGS

NORMAL

GDS
HbA1C UREUM CREATININE SGOT SGPT NATRIUM KALIUM

269
5.9 45 1.4 47 32 143 3.8

140
4-6 10-50 L(<1.3), P(<1,1) <38 <41 136-145 3.5-5.1

CHLORIDE

1109

97-111

Thorax Photo
Interpretation: In Normal Limit

Echocardiography

Echocardiography
Interpretation Sistolic and diastolic LV disfunction, EF 38% LVH (+) Anterior, apical, apico septal, and mid septal hipokinetic EV function good (TAPSE 1,9) MR Mild-Mud

Working Diagnosis
STEMI Anterior Wall Onset 9 Hrs KILLIP II Hypertention Gr I DM type II

Initial Management
Bed rest Cardiac Diet O2 3-4 ltr/min

IVFD NaCl 0,9 % 10 drips/min

Isosorbid dinitrat : Cedocard 2mg/amp/jam Simvastatin 20 mg 0 0 1 Anti platelet aggregation : - Aspirin : Aspilet 80 mg loading dose 2 tab 80 mg 0 1 0 - Clopidogrel: Plavix 75 mg loading dose 4 tab 75 mg 1 0 0 Anticoagulant : Arixtra 2,5 mg/24 h/ SC ARB : Valsartan 80 mg 0-0-1 Anti anxietas : Alprazolam 0,5 mg 0 - 0 - 1 Stool softener : Laxadyn syrup 0 - 0 - 2C Novorapid 6-6-6 Lantus 0-0-12

DISCUSSION :

Acute Coronary Syndrome

(ST-Elevation Myocard Infarction)

 Myocardial ischemia is caused by imbalance between myocardial oxygen supply and myocardial oxygen consumption.
Myocardial infarction (MI) is the rapid development of myocardial necrosis.

EUROPEAN HEART JOURNAL. GUIDELINES ON THE MANAGEMENT OF STABLE A NGINA PECTORIS

Regions of the Myocardium

Lateral I, AVL,V5-V6

Inferior II, III, aVF

Anterior / Septal V1-V4

EUROPEAN HEART JOURNAL. GUIDELINES ON THE MANAGEMENT OF STABLE A NGINA PECTORIS

Diagnosis

WHO Diagnostic Criteria

Clinical history of ischaemic type chest pain lasting >20 minutes Changes in serial ECG tracings Rise and fall of serum cardiac biomarkers such as creatinine kinase-MB fraction and troponin

HTTP://EN.W IKIPEDIA.ORG/WIKI/MYOCARDIAL_INFARCTION

CARDIAC BIOMAKERS

RISK FACTORS FOR ATHEROTHROMBOSIS

Hypercoagulable states
Homocysteinemia Diabetes Obesity Genetics Life-style (e.g, smoking, diet, lack of exercise)
Hyperlipidemia

Hypertension Gender Infection? Age

Atherotrombotic Manifestations (MI, Ischemic stroke, Vascular death)

American Heart Association, Heart and Stroke facts: 1997 Statistical supplement; Wolf Stroke 1990;21 (SUPPL 2):II-4II-6;Laurila et al. arterioscle TrombVasc bio 1997;17:2910-2913;Grau et al. Stroke 1997;26;1724-1729; Graham et al JAMA 1997;277: 1775-1781;Brigden Postgrad Med;101(5);249262

Treatment
Relieve pain

Hemodinamic stabilitation
Miokardial reperfusion

Prevent the complication

KABO P. BAGAIMANA MENGGUNAKAN OBAT-OBAT KARDIOVASKULAR SECARA RASIONAL. 2010

Treatment
Oxygen

Surgical revascularization
PTCA (percutaneous transluminal coronary angioplasty)

Nitrate
Anti platelet agent Anti koagulan

Morphine / pethidine
Trombolitic -blocker

CABG (coronary artery bypass grafting )

ACE inhibitors
Lipid lowering agent
KABO P. BAGAIMANA MENGGUNAKAN OBAT-OBAT KARDIOVASKULAR SECARA RASIONAL. 2010

Prognosis
KILLIP CLASSIFICATION
Class Description no clinical signs of heart failure I rales or crackles in the lungs, an S3, II and elevated jugular venous pressure acute pulmonary edema III cardiogenic shock or hypotension IV (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction Mortality Rate (%) 6 17 30 - 40 60 80

HTTP://EN.W IKIPEDIA.ORG/WIKI/KILLIP_CLASS

TIMI score for UAP and NSTEMI

1. Age > 65 years 2. More than 3 risk factors - hypertension, diabetes mellitus, smoking, family history, dyslipidaemia

3. Prior coronary angiogram showing > 50% stenosis

4. Aspirin use in the past 7 days 5. At least 2 episodes of rest pain in the past 24 hours 6. ST deviation on admission > 1 mm 7. Elevated cardiac markers - CK, CKMB, Troponin T Low 0-2 : < 8.3% risk of adverse cardiac event Intermediate 3-4 : < 19.9 % risk of adverse cardiac event High 5-7 : up to 41% risk of adverse cardiac event
HTTP://DOKNOTES.WIKIDOT.COM/TIMI-SCORE-FOR-UNSTABLE-ANGINA-AND-NSTEMI

Thank You