st sement elevation myocardial infarction (stemi)

8/13/2019 St Sement Elevation Myocardial Infarction (Stemi)

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ST SEGMENT ELEVATION MYOCARDIALINFARCTION (STEMI)I N F E R I O R O N S E T > 2 4 H O U R S , K I L L I P 1 , T I M IS C O R E 2 / 1 4 ( 2 , 2 % )

PRESENTED BY : NUR HALIMATUSSANIAHC111 09 849

SUPERVISED BY : DR PENDRIK TANDEAN, Sp PD-KKV, FINASIM

KEPANITERAAN KLINIK BAGIANKARDIOVAKULER

UNIVERSITAS HASANUDDINMAKASSAR

2013


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PATIENT IDENTITY

MR number : 636103

NAME : MR A

AGE : 47 years old

DATE OF ADMISSION: 7 TH November 2013


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HISTORY TAKING

Chief complaint: Chest pain

Occurred 3 days before admitted,At the beginning, the chestpain was like being sliced, burned, the painwas radiated from the chest till the jaw

The pain occur while the patient carry boxes of paper.

Duration of chest pain is about an hour and did not relieved by rest.

Patient have been admitted in RS Pare-pare before he been refferred toRSWS.

Shortness of breath (-) , sweating (+), weakness (-), and nausea (-),Cough (-), fever (-)

Proxymal Nocturnal Dyspneu (-), Dyspneu On Effort (+), Ortopneu (-)Defecation and urination : normal


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HISTORY OF PAST ILLNESS

History of hypertension ( + ) since 3 years ago with uncontrolled

therapy

History of Osteorthritis (+) 2 years ago

History of diabetes mellitus (-)

History of family with CVD ( - )

History of smoking (+) 1 year ago, 2 packet daily

History of heart disease (-)History of family with heart disease (-)

History of asthma (-)

History of gastritis (-)


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RISK FACTORS

Modifiable

- Hypertension (+)- Tobacco use (+)

NonModifiable

Gender :Male


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PHYSICAL EXAMINATION

General status Moderate

illness/wellnourished/conscious

Vital sign BP: 170 / 90 mmHg

HR: 70 x/min RR: 18 x/min

T : 36.5 0 C


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REGIONAL STATUS

Head ExaminationEyes : anemia (-), icterus (-)Lip : cyanosis (-)

Neck : lymphadenopathy (-), JVP R +0 cmH2O

Thoracal ExaminationInspection : symetric, normochestPalpation : mass (-), tenderness (-), VF R=LPercussion : sonor

Auscultation : breath sound : bronchovesicular,ronchi -/-, wheezing -/-


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REGIONAL STATUS

Heart ExaminationInspection : IC wasnt visible Palpation : IC wasnt

palpablePercussion : normal heartsizeUpper border : left 2 nd ICSLower border : left 5 th ICSRight border : right

parasternalis lineLeft border : leftmedioclavicular lineAuscultation : Regular of I/IIheart sound, murmur (-)

Abdominal ExaminationInspection : flat andfollowing breath movementAuscultation : peristaltic sound(+) , normalPalpation : liver and spleenunpalpablePercussion : tympani, ascites(-)

ExtremitiesOedema : pretibial (-),dorsum pedis (-)


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INTERPRET TION

Rhythm : SinusHeart rate : 56 bpmRegularity : regulerAxis : Normoaxis, 20 o

QRS duration : 0.92 sPR interval : 0.12sP wave : 1.08sST Segment : T inverted at lead II,III,AVFConclusion : Possible Inferiormyocardial infarction, probably oldsummary


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ECHOCARDIOGRAPHY 7/11/2013


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DESCRIPTION OF WALL MOTION, MASSES,VALVES, PERICARDIUM- LV systolic function, EF 67%

- Dimension of Cardiac compartment : normal- LVH: (-)- Hipokinetic of inferior base + inferoseptl- RV systolic function is good, TAPSE : 1.8cm

- Cardiac valve :- Mitral : function and movement good- Aorta : 3 cuspis, calcification (-), function &

movement normal- Tricuspid : function & movement normal- Pulmonal :function & movement normal

- E/A > 1 (Pseudonormal)

- Conclusion :LV diastolic dysfunction, EF 67%, Hipokinetic of inferior base + inferoseptl e.cCAD


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L BOR TORY EX MIN TION

C o m p

l e t e b l o o d

WBC : 8.11 x 10 3 HGB : 14.3 g/dlHCT : 42.9 %RBC : 4.73 x 106 /mm 3

PLT : 247x 10 3 /mm 3 Cardiac enzyme

CK : 1393 u/L CK MB : 19 u/L Troponin T : 0,33 u/LElectrolyte

Sodium :143 mmol/lPotassium : 4.4 mmol/lChloride : 108 mmol/l

B l o o d c h e m

i s t r y

Random blood sugar: 106 mg/dlSGOT : 71 u/lSGPT : 35 u/lUreum : 28Creatinin : 0.7PT : 9,9APTT : 24,4Total Cholesterol : 212mg/dlHDL : 35 mg/dlLDL : 176 mg/dlTriglyseride : 187 mg/dl


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WORKING DIAGNOSISSTEMI Inferior onset 1 hour,

KILLIP I


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MANAGEMENT

O 2 2 LPM (via nasal canule)

Cardiac Diet

IVFD NaCl 0,9% loading 500 cc/24 hoursVasodilator

Cedocard 0.5mg/hour via SP

Anti Platelet AggregationASA (Aspilet) 2 x 80 mg

Clopidogrel (Plavix) 4 x 75 mgACEI

Captopril 3 x 12,5mg

Anti cholesterolHMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg)

AnxiolyticBenzodiazepin (Alprazolam) 0,5 mg 0- 0 - 1

LaxativeLaxadin syrup 1 x 2 cth


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ACUTE CORONARY SYNDROMEST SEGMENT ELEVATIONMYOCARDIAL INFARCTION

D I SCU SSI O N


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DEFINITION

- Acute coronary syndrome (ACS) covers a range of

disorders including myocardial infarction (heartattack) and unstable angina that are caused by the

same underlying problem.

- The underlying problem is a sudden reduction of

blood flow to part of the heart muscle. This is usually

caused by a blood clot that forms on a patch ofatheroma within a coronary artery (which is

described below).


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DIAGNOSIS OF ACS

Ischemic symptoms Prolonged pain

(usually >20 mins) constricting,crushing, squeezing

Usually retrosternal

location, radiating toleft chest, left arm;can be epigastric

Dyspnea Diaphoresis Palpitations Nausea/vomiting Light headedness Sense of impending

doom

DiagnosticECGchanges

Serum cardiacmarkerelevations

TroponinT CK-MB

CK Myoglobin


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LOCATION OF CHEST PAIN DURING HEART ATTACK


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SERUM CARDIAC BIOMARKERS


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RISK FACTOR FOR ACS


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PROGNOSIS BASED ON KILLIP CLASSIFICATION


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INITIAL TREATMENT

Fixing the chest pain and fearness

Bed rest Diet O 2 2-4 lpm via nasal prongs or face mask Sublingual/oral/IV nitroglycerine Antiplatelet: aspirin and clopidogrel Morfin/petidine Diazepam 2-5mg/8 hour

Stabilizing the hemodynamic (blood pressure and peripheralpulse control)

-blocker if there is no contraindication Calcium channel blocker (CCB) ACE-Inhibitor

Reperfusion of the myocard

Thrombolytic


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COMPLICATIONS

Arrythmia Heart failure Cardiogenic shock

Rupture ofventricle

septum/wall

Rupture ofchordae tendineae Pericarditis

Tromboemboli


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SECONDARY PREVENTION Smoking cessation

Blood pressure control (less than

140/90 mm Hg, or less than 130/80

mm Hg in patients with diabetes or

chronic kidney disease)

Lipid management (LDL-C level

substantially less than 100 mg per

dL; non HDL-C level less than 130

mg per dL in patients with

triglyceride levels 200 mg per dL or

greater)

Physical activity (30 minutes at least

five days per week)

Weight management (BMI 18.5 to

24.9 kg per m 2; waist circumference

less than 40 inches in men, less

than 35 inches in women)

Diabetes management (A1C less

than 7 percent)

Antiplatelet and anticoagulant

therapy

Renin-angiotensin-aldosterone

system blocker therapy

st sement elevation myocardial infarction (stemi)

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