livia sagita ruslim cardio stemi.ppt

7/27/2019 Livia sagita ruslim cardio stemi.ppt

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ST Elevation Myocardial Infarction(STEMI)

Inferior Onset 7 hours, KILLIP I

By:Livia Sagita Ruslim

Supervisor :

dr. Pendrik Tandean, Sp PD-KKV. FINASIM


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PATIENT IDENTITY

Name : Mr. AR

Gender : Male

Age : 54 years old

Address : Perintis Kemerdekaan street, Makassar

Registration no. : 618014

Date of admission : 08th July 2013


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ANAMNESIS

Chief Complaint: Chest pain

Present Illness History :

The chest pain began for + 7 hours before he was admitted to

Wahidin Sudirohusodo hospital, occurred when he was cleaning

a post. The pain is described like dull heavy feeling on the chest,

continuously, did not radiate to back and left arm and the pain

not improved by resting. The chest pain accompanied with

dizziness and cold sweating a lot.


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ANAMNESIS

Nausea (-), vomiting (-)

Cough ( - ), Shortness of breath ( - ), Fever (-)

Dyspnea on effort (-), Paroxysmal nocturnal dyspnea(-)

Urination normal

Defecation normal


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ANAMNESIS

Previous Illness History

History of heart disease ( - )

History of hypertension (-)

History of diabetes melitus (-)

History of dyslipidemia (-)


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ANAMNESISPersonal History

Smoking (+) 2 packs/ day for 30 years

Alcohol (+) 3L/ day for 10 years STOP

Family History

Father () old aged

Mother () old aged


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ANAMNESIS

RISK FACTOR

Modified Risk Factor

History of smoking (2 packs of cigarette/day for 30 years)

Non-modified risk factor:

Gender : male

Age : 54 year old


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PHYSICAL EXAMINATION

General appearance : Moderate illness/well nourished/composmentis

Vital Signs:

BP : 110/70 mmHg RR : 22 x/min BW : 97kg

HR : 84x/min T : 36,6C H : 173cm

Head : Anemia (-) , Icterus (), Palpebra Edema (-)

Neck : JVP R+0 cmH20

Lung : Vesikuler Rhonchi -/- Wheezing -/-


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Cor : I : Ictus cordis not visible

P : Ictus cordis not palpable

P : Dull, normal heart size

-Upper border : left 2nd ICS

-Right border : right parasternalis line

-Left border : left medioclavicular line

- Lower border : left 5th ICS

A : Heart Sound I/II pure regular, murmur(-)


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Abdomen :

Inspection : symmetrical big and following breath

movement

Auscultation : peristaltic sound (+) , normal

Palpation : liver and spleen unpalpable, mass (-)

Percussion : tympani, ascites (-)

Extremities : Edema -/-


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CHEST X-RAY (9th July 2013)

Cor : expand with CTI:0.59, waist of heartconcaved, apex lifted

(RVE), aorta dilatation Result : Cardiomegaly

with aorta dilatation.

a

b

c


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ECG FINDINGS


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Rhythm : AV Block

Frequency : 45 x/ minute

Axis : Normoaxis

P Wave : 0.08s

PR Interval : 0.36s

QRS Complex : 0.06s

ST Segment : ST Segments Elevation in leads II, III, aVF

T Wave : T wave inverted in leads III

Conclusion : Inferior Acute Myocardial Infarction, AV Block 1stdegree

ECG INTERPRETATION


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EChocardiography

LV systolic function decreased --- EF 33.90%

LVH (+) --- IVSd 17.7mm


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Complete blood count

WBC : 10.86 x 103/ul

RBC : 4.92 x 106/uL

HGB : 11.7 gr/dl

HCT : 34.8%

PLT : 261 x 103/l

Enzymes

CK :603 U/L

Trop T : 0.34

Coagulation Time

PT : 11.6s

APTT : 24.5s

Blood chemistry

Ureum : 42 mg/dl

Creatinine : 1.6 mg/dl

SGOT : 37 u/dl

SGPT : 14 u/ dl

GDS : 120 mg / dl

Uric acid : 6.5 mg / dl

Cholesterol total : 188 mg/dl

HDL : 32 mg / dl

LDL : 138 mg / dl

Triglyceride : 159mg / dl

LABORATORIUM FINDINGS


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DIAGNOSIS

STEMI Inferior onset 7 hours, Killip I

AV Block 1stdegree


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INITIAL MANAGEMENT

Bed rest

O2 2-4 lpm ( via nasal canule )

IVFD NaCl 0,9% 500cc/24 jam

Streptokinase 1.5million U / iv

Arixtra 2.5mg/24hrs/sc

Aspilet 162 mg qd (chewed) loading dose

Clopidogrel (Plavix) 4x75 mg qd

loading dose

Simvastatin 20 mg qd

Laxadin syr 1x2cth


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ADVISE

Coronary Angiography


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ACUTE CORONARY

SYndrome


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DEFINITION

Acute coronary syndromes (ACS) is the clinical

manifestation of the critical phase of coronary

artery disease.

Based on ECG and biochemical markers it is

distinguished from :

1)ST elevation myocardial infarction (STEMI)

2)Non-ST elevation myocardial infarction

(NSTEMI)

3)Unstable Angina


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PATHOPHYSIOLOGY

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

1 2 3

4 5 6


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PATHOPHYSIOLOGY


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Non-Modifiable

Gender and age.

Men, older than age 45

Women, older than age 55

Family history

Anyone with a 1stdegreemale or female relative who

developed CAD before age 55

or 65.

Modifiable

Smoking

Hypertension

Diabetes Mellitus

Dyslipidemia

Obesity

A desentary lifestyle

Stress

Risk factors

Overbaugh KJ. Acute Coronary Syndrome. AJN. May 2009: 109 (5):43


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ACUTE CORONARY SYNDROME

Daga LC, Kaul U, Mansoor A. Approach to STEMI and NSTEMI. Supplement to JAPI. 2011

(59):19.

Diff U t bl A i NSTEMI STEMI


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Differences Unstable Angina NSTEMI STEMI

Cause Thrombus partially orintermittently occludes the

coronary a.

Thrombus partially or

intermittently occludes the

coronary a.

Thrombus fully occludes the

coronary a.

Signs and

symptoms

chest pain with/without

radiation to arm, neck, back or

epigastric region

Shortness of breath, diaphoresis,nausea, lightheadedness,

tachycardia, tachypnea,

hypotension/ hypertension, SaO2and rhythm abnormalities

Occurs at rest or with exertion;

limits activity



epigastric region





limits activity

Longer in duration and more

severe than in UA



epigastric region





limits activity

Longer in duration and more

severe than in UA (infarction

occurs if perfusion is not restored)

Diagnostic Findings ST-segment depression or T-waveinversion on ECG

Cardiac biomarkers not elevated

ST-segment depression or T-wave

inversion on ECG

Cardiac biomarkers are elevated

ST-segment elevation or new

LBBB on ECG

Cardiac biomarkers are

elevated

Treatment O2 to maintain SaO2 level >90%Nitroglycerin or morphine to

control pain-blockers, angiotensin-

converting enzyme inhibitors,

statins, c`lopidogrel, LMWH, and

glycoprotein Iib/IIIa inhibitors

O2 to maintain SaO2 level >90%

Nitroglycerin or morphine to



statins, clopidogrel, LMWH, and

glycoprotein Iib/IIIa inhibitors

Cardiac catheterization and

possible PCI for patients with

ongoing chest pain,

hemodynamic instability, or

increased risk of worsening

clinical condition

O2 to maintain SaO2 level >90%

Nitroglycerin or morphine to



statins, clopidogrel, LMWH

PCI within 90 minutes of

medical evaluation

Fibrinolytic therapy within 30

minutes of medical evaluation

Anderson JL, et al. Circulation 2007;116(7):e148-e304; Hazinski MF, et al., editors.Handbook of emergency cardiovascular care for healthcare providers.

Dallas:American Heart Association; 2008.


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RISK SCORE FOR ACS

TIMI Risk Score for NSTEMI

Historical

Age 65 1

3 risk factors for CAD 1

Known CAD (Stenosis 50%) 1Aspirin use in past 7 days 1

Presentation

2 anginal events in 100 2 points

Killip II-IV 2 points

Weight < 67 kg 1 point

Presentation

Anterior STE orLBBB

1 point

Time to rx > 4 hrs 1 point

Risk Score = Total (0-14)

Daga LC, Kaul U, Mansoor A. Approach to STEMI and NSTEMI.

Supplement to JAPI. 2011 (59):20.


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Management


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Initial Treatment

1. Bed Rest

2. Diet

3. Oxygen (2-4L/mnt)

4. Anti platelet therapy :

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

indefinitely.

- Clopidogrel 300-600mg loading dose and 75mg daily continued for at least 14

days and up to 12 months.

5. Nitroglycerin

0.4 mg SL tablets every 3-5 min up to 3 times; if effect is not sustained, cancontinue with an IV drip of 50mg in 250mL Dextrose 5%.

2013 ACC/AHA Guideline STEMI


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Initial Treatment

6. Morphine 2-5mg iv Q5-30min

7. Fibrinolytic therapy:

a) Streptokinase 1.5million units iv

b) Tenecteplase 0.5mg/kg body weight iv

8. Anticoagulation therapy:

a) Low Molecular Weight Heparins ( Fondaparinux)

2.5mg/24hrs/sc for up to 8 days post-MI.

9. Statins

Simvastatin 20mg qd

Options for Transport of Patients With


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Options for Transport of Patients With

STEMI and Initial Reperfusion Treatment

EMS Transport

Onset of

symptomsof STEMI

9-1-1

EMSDispatch

EMS on-scene

Encourage 12-lead ECGs. Consider prehospital fibrinolytic

if capable and EMS-to-needle

within 30 min.GOALS

PCI

capable

Not PCI

capable

Hospital fibrinolysis:

Door-to-Needlewithin 30 min.

Inter-

HospitalTransfer

Golden Hour = first 60 min. Total ischemic time: within 120 min.

Patient EMS Prehospital

fibrinolysisEMS-to-needle

within 30 min.

EMS transport

EMS-to-balloon within 90 min.Patient self-transport

Hospital door-to-balloon

within 90 min.

5

min.

8

min.

Antman EM, et al. J Am Coll Cardiol 2008. Published ahead of print on December ;

ACC/AHA STEMI Guideline 2009


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PROGNOSIS

Class Description Mortality Rate(%)

I No clinical signs of heart failure 6

II Rales or crackles in the lungs, an S3, andelevated jugular venous pressure

17

III Acute pulmonary edema 30 - 40

IV Cardiogenic shock or hypotension(systolic BP < 90 mmHg), and evidenceof peripheral vasoconstriction

60

80

KILLIP CLASSIFICATION


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THANK YOU

livia sagita ruslim cardio stemi.ppt

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