STEMI EXTENSIVE ANTERIOR > 24 HOUR ONSET KILLIP I

Presented by: Andi Ita Maghfirah Supervisor : Dr.dr.Idar Mappangara, Sp.PD, Sp.JP, FIHA, FINASIM, FICA
Department of Cardiology and Vascular Medicine Medical Faculty of Hasanuddin University Makassar 2013

PATIENT IDENTITY
Medical Record Name Gender Age Address Date of admission 2013 : 621999 : Mr. LH : Male : 58 years old : Rajawali : August 9th

HISTORY TAKING
Chief complaint: Chest Pain
History of Present Illness: The chest pain began since 7 days before he was admitted to Wahidin Sudirohusodo Hospital. Damning since 5 days ago. The sensation of chest pain suddenly appeared when the patient was working. The pain is described like dull heavy feeling on the left part of the chest, not spreading . The chest pain felt continuously more than 20 minutes duration, and not relieved by rest. The chest pain was accompanied with cold sweat and feeling nauseated. Theres no history of any chest pain before. Theres also have hystory of hypertension since 10 years ago, no history of fever and diabetes. History of any heart disease in the family denied. Patient been smoking for almost 30 years with 12 cigarette each days . Patient has history of epigastric pain. Urination and defecation were normal.

HISTORY TAKING
History of Past Illness:
History of chest pain (-)

History of smoking (+ ) for 30 years

History of hypertension (+) for 10 years 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

History of epigastric pain (+)

RISK FACTOR

Non Modifiable
Gender: Male Age: 58 yo

Modifiable
Smoking (+) Hypertension (+) Obesity (+)

PHYSICAL EXAMINATION
General Status Moderate illness/normal weight/conscious Vital Signs BP : 140/90 mmHg HR : 98 bpm, regular RR : 20 tpm Temp : 36.6C Weight: 64 kg Height : 158 cm

PHYSICAL EXAMINATION
Head Examination Eyes : Anemic -/-, Icterus -/ Lips : Cyanosis (-) Neck : Lymphadenopathy (-), JVP R+0 cmH2O Thorax Examination Insp. : Symmetrical R=L , normochest Palp. : Mass (-), tenderness (-), Vocal Fremitus R=L Perc. : Sonor Ausc. : Vesicular Ronchi -/-, Wheezing -/-

PHYSICAL EXAMINATION
Cardiac Examination
Insp. : IC not visible Palp. : IC not palpable Perc. : Dull

Right border : Right parasternalis line Left border : ICS 5 midclavicularis 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
Interpretation: Rhythm QRS-Rate P-Wave PR-Interval QRS Complex Axis ST-Segment T-Wave : Sinus ritme : HR 100 bpm, reguler : 0.12 sec : 0.20 sec : 0.11 sec on v1 : Normal axis 50 : ST-elevation on lead I, aVL, V2-V6 : Normal

Conclusion: Sinus Rythmn, HR 100 bpm, normoaxis . ST-elevation on lead I ,aVL and lead V2-V6. complex QRS widen normal on v1, Acute Extensive Myocardiac Infarct

LABORATORY EXAMINATION

WBC HB PLT HCT GDS Ureum Creatinin Uric acid

: 14.9 : 14,5 gr/dl : 258.000 : 45,3 % : 108 mg/dl : 38 mg/dl : 14 mg/dl : 6,1 mg/dl

CK CKMB Trop. T Na K Cl SGOT SGPT PT APTT

: 398 U/L : 26 U/L : >2.0 : 145 mmol/l : 3,69 mmol/l : 107 mmol/l : 163 U/L : 398 U/L : 12,4 control 10,5 : 24,2 control 23,4

DIAGNOSIS

- STEMI Extensive Anterior with >24 hour onset Killip I

INITIAL MANAGEMENT
Bed rest O2 2-4 LPM (via nasal canule) Heart Diet IVFD NaCl 0,9% loading 500 cc/24 hours Anti Platelet Aggregation ASA (Aspilet) loading dose 80 mg (2 x 80 mg) maintenance 1-0-0 Clopidogrel (Plavix) loading dose 75 mg (4 x 75 mg) maintenance 0-1-0 Anti cholesterol HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg) 0-0-1 Anti coagulant Low Molecule Weight Heparin(Fondaparinux(Arixtra)) 2,5 mg/24 hr/SC Anxiolytic Benzodiazepin (Alprazolam 1 x 0,5 mg) Laxative Laxadin syrup 1 x 2 cth Anti hypertension Ace-inhibitor (Captopril) 3 x 12,5 mg

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

PATHOPHYSIOLOGY
Vulnerable Plaque Thrombosis Vasospasme Plaque disruption and thrombosis that result in complete coronary artery occlusion leads to transmural ischemia and necrosis, the hallmark of ST-segment elevation myocardial infarction (STEMI)

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

Modifiable
Smoking Hypertension Diabetes Mellitus Dyslipidemia Obesity Lack of physical activity

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

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 SGOT

CK-MB

CK

LDH

Myoglobin

CARDIAC BIOMARKER

DIAGNOSIS

WHO DIAGNOSTIC CRITERIA

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

INITIAL MANAGEMENT
Fixing the chest pain and fearness Bed rest Diet O2 2-4 lpm Nitroglycerin: 0,4 mg SL tablets every 3-5 minutes up to 3 times; if effect is not sustained, can continue with an IV drip of 50 mg in 250 ml dextrose 5% Antiplatelet : Aspirin: 162-325 mg chewed immediately and 81-162 mg continued indefinetely Clopidogrel 300-600 mg loading dose and 75 mg daily continued for at least 14 days and up to 12 months. Morphine 2-5 mg IV every 5-30 minutes Pethidine 12,5 mg/IV Diazepam 2-5mg/8 hour Stabilizing the hemodynamic (blood pressure and pheripheral pulse control) -blocker Calcium channel blocker (CCB) ACE-Inhibitor Reperfusion of the myocard Thrombolytic: streptokinase 1,5 million units/IV

PROGNOSIS KILLIP CLASSIFICATION

Class I 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

II III

17 30 - 40

IV

60 80

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