Lapkas Pp(STEMI)

7/30/2019 Lapkas Pp(STEMI)

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Case ReportSTEMI INFERIOR ONSET 15 JAM

KILLIP I TIMI RISK 3/14

Pembicara

- Ismail Lubis (080100152)

Pembimbing

dr.Parlindungan Manik,SpJP(K)


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DEFINISISuatu sindroma klinik yang menandakan

adanya iskemia miokard akut, terdiri dari :

Infark miokard akut Q wave (STEMI)

Infark miokard akut non-Q (NSTEMI)

Angina pektoris tidak stabil (UAP)

Ketiga kondisi ini sangat berkaitan erat, berbeda hanyadalam derajat beratnya iskemi dan luasnya miokard

yang mengalami nekrosis.


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PATOGENESIS

Umumnya disebabkan oleh

aterosklerosis koroner

Plak aterosklerosis ruptur terbentuktrombus diatas ateroma yang secara akut

menyumbat lumen koroner

Apabila sumbatan terjadi secara total hampir seluruh dinding ventrikel akan

nekrosis


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FAKTOR RESIKO Faktor resiko biologis yang tak dapat diubah :

1. Usia dan jenis kelamin

2.Ras

3.Riwayat keluarga


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Faktor-faktor

resiko yang masihdapat diubah


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CAD

Atherosclerosis

Risk Factors( , BP, DM,

Insulin Resistance, Platelets,Fibrinogen, etc)

The cardiovascular continuum ofevents

DYSLIPIDEMIA

MyocardialIschemia

plaque

Ischemia = oxygen supply

and demand imbalance


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CAD

Atherosclerosis




DYSLIPIDEMIA

MyocardialIschemia

CoronaryThrombosis


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CAD

Atherosclerosis




DYSLIPIDEMIA

MyocardialIschemia

CoronaryThrombosis

ACS


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DIAGNOSIS Anamnesis

EKG Biomarker Kerusakan Jantung

Minimal 2 SKA


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HISTORY

PRODROMAL SYMPTOMS

History very valuable to establish D/. Prodoma : chest discomfort

unstable angina

1/3 symptoms for 1 4 wks

20% symptoms for < 24 hrs

Malaise, exhaustionNATURE OF PAIN

Most patientssevere prolonged, 30 minutes - hours

Constricting, crushing, oppressing, compressingheavy weight or squeezing in chest

Choking, vise-like, heavy pain or stabbing, knife-like, boring orburning discomfort

Location : retrosternal, spreading frequently to both sides of thechest with predilection to the left side

Often pain radiates down ulnar aspect of left arm, producingtingling sensation in left wrist, hand and fingers


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NATURE OF PAIN

SOME INSTANCES : pain begins in epigastrium, and simulates

abdominal disorder

Sometimes pain radiates to shoulders, upper extremities, neck, jaw and

interscapular region favoring the left side

Elderly : no chest pain but acute left ventricular failure and chest

tightness or marked weakness or syncope

Pain arises from nerve endings in ischemic or injured, but not necrotic,

myocardium

OTHER SYMPTOMS

50% nausea or vomiting in transmural infarctsOccasionally diarrhea, profound weakness, dizziness, palpitation, cold

perspiration, sense of impending doom

Occasionally : cerebral embolism or systemic arterial embolism


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Pain Patterns with Myocardial Ischemia


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Anamnesis untuk UAP

3 kategori presentasi klinik UAP:

Angina saat istirahat (resting angina)

Angina awitan baru (new onset angina)

Angina yang bertambah berat (increasingangina)

Riwayat penyakit dahulu :

Riwayat angina on effort, infark atauoperasi pintas

Riwayat penggunaan nitrogliserin

Identifikasi faktor-faktor risiko


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BLOOD PRESSURE

Majority normotensive, but syst. BP may decline and diast.

BP may rise Half of pts with inferior MI parasympathetic

stimulation : hypotension, bradycardia or both (Bezold Jarisch reflex)

half of pts with anterior MI, sympathetic excess :hypertension, tachycardia or both

TEMPERATURE AND RESPIRATION

Most pts with extensive MI fever within 24-48 hrs,fever resolves by 4th or 5th day

Respiration due to anxiety and pain, in LV failure : resp.rate correlates with degree of heart failure


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Pemeriksaan Penunjang

Pemeriksaan EKG

Gambaran EKG infark miokard akut Q-wave (STEMI):

Elevasi segmen ST 1 mm pada 2 sadapanextremitas

Atau 2 mm pada 2 sadapan prekordial yangberurutan

Atau gambaran LBBB baru atau diduga baru


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Gambaran EKG infark miokard akut non-Q-wave (NSTEMI) atau angina pektoris tidakstabil (UAP) :

Depresi segment ST atau gelombang T terbalikpada 2 sadapan berurutan

Inversi gelombang T minimal 1 mm pada 2sadapan atau lebih yang berurutan.

Perubahan segment ST saat keluhan dankembali normal saat keluhan hilang sangatmenyokong UAP


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T-wave inversion


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LOKASI SKA


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Biomarker Kerusakan Jantung

BIOMARKER WAKTU PUNCAK ELEVASI KEMBALI NORMAL

CK-MB 3 12 jam 24 jam 48 72 jam

(cTn)T 3 12 jam 24 jam 5 10 hari

(cTn)I 3 12 jam 12 jam 2 hari 5 14 hari


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PENATALAKSANAAN


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ACS

Coronary

Thrombosis

MyocardialIschemia

CAD

Atherosclerosi

s


Insulin Resistance,Platelets, Fibrinogen, etc)

The cardiovascular continuum of events

DYSLIPIDEMIA

Arrhythmiaand

Loss ofMuscle

Remodeling

VentricularDilatation

Congestive

HeartFailure

End-stageHeart Disease


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DELAY TO THERAPY

1. From onset of symptoms to patient recognition

2. Out-hospital transport

3. In-hospital evaluation


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ISCHEMIC CHEST PAINALGORYTHM

Chest pain suggestive of ischemia


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ISCHEMIC CHESTPAIN

TYPICAL ANGINA EQUIVALENTANGINA

1. CHESTDISCOMFORT

2. LOCATION

3. RADIATION

4. UNLIKELINESS

1. NO CHEST DISCOMFORT

2. LOCATION

3. INDIGESTION4. UNEXPLAINED

WEAKNESS

5. DIAPORESIS

6. SHORTNESS OF BREATH


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Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED generaltreatment

Acute coronary syndrome algorithm


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Immediate ED assessment ( 10 min) Vital sign

Oxygen saturation

Obtain IV access

Obtain ECG 12 lead

Brief history and physical exam

Check contraindication for fibrinolytic

Initial serum cardiac markers

Initial electrolyte and coagulation

study

Portable chest x-ray ( 30 minutes)

Immediate ED general treatment

O2 at 4 L/min (maintain O2 sat 90%) Aspirin 160-325 mg

Nitroglycerin SL, spray, or IV

Morphine IV 2-4 mg repeated every

5-10 minutes (if pain not relieved

with nitroglycerine)

Memory: MONA greets all patients


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Review initial 12 lead ECG


Immediate ED assessment and immediate ED general treatment



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ST elevation or new or

presumably new LBBB

strongly suspicious for

injury






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ST-depression or

dynamic T-wave

inversion strongly

suspicious for injury


presumably new LBBB


injury







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ST-depression or

dynamic T-wave

inversion strongly


(UA/NSTEMI)


presumably new LBBB


injury (STEMI)





Normal or non-

diagnostic changes

in ST-segment or T-

waves (intermediate/

low-risk UA)



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Start adjunctive treatment

Normal or non-

diagnostic changes

in ST-segment or T-

waves (intermediate/

low-risk UA)

ST-depression or

dynamic T-wave

inversion strongly


(UA/NSTEMI)


presumably new LBBB


injury (STEMI)






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1. Beta-adrenergic receptor blocker

2. Clopidogrel

3. Heparin (UFH or LMWH)

ADJUNCTIVE TREATMENT

(Do not delay reperfusion)



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Normal or non-

diagnostic changes in

ST-segment or T-

waves

ST-depression or dynamic

T-wave inversion strongly



presumably new LBBB


injury





Time from onset of

symptoms

- Reperfusion strategy: PCI (90

min) or fibrinolysis (30 min)

- ACE-I/ARB

- Statin

12 hours



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Time from onset of

symptoms

- Reperfusion strategy: PCI (90 min) or

fibrinolysis (30 min)

- ACE-I/ARB within 24 hours of onset

- Statin

12 hours


Normal or non-


ST-segment or T-

waves





presumably new LBBB


injury







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Heparin (UFH/LMWH)

Glycoprotein IIb/IIIa receptor inhibitors

-Adrenoreceptor blockers Clopidogrel

Adjunctive treatment



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Time from onset of

symptoms



- ACE-I/ARB within 24 h of

symptom onset)

- Statin

12 hours


Normal or non-


ST-segment or T-

waves





presumably new LBBB


injury





12 hrs Admit to monitored bedAssess risk status

- High risk: early invasive

strategy

- Continue ASA, heparin,

ACE-I, statin


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VERY HIGH-RISK PATIENT

1. Refractory chest pain

2. Recurrent/persistent ST deviation

3. Ventricular tachycardia

4. Hemodynamic instability

5. Sign of pump failure

6. Shock within 48 hours



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Time from onset of

symptoms



- ACE-I/ARB within 24 h of

symptom onset)

- Statin

12 hours 12 hrs


Normal or non-


ST-segment or T-

waves





presumably new LBBB


injury





Admit to monitored bed

Assess risk status

- High risk: early invasive

strategy

- Continue ASA, heparin,

ACE-I, statin

Develops high or

intermediate risk criteria

or troponin-positive

Monitored bed in ED

Develops high or

intermediate risk criteria

or troponin-positive

No evidence of ischemia and MI: discharge with follow-up


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P b t P P t


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Obat-obat untuk mengontrol keluhan iskemiaharus dilanjutkan

Aspirin Beta-blocker

ACE inhibitor

Pengobatan Pasca Perawatan

Berhenti merokok

Pertahankan BB optimal

Aktivitas fisik sesuai dengan hasil treadmill

Diet

Rendah lemak jenuh dengan kolesterol, bila perludengan target LDL < 100 mg/dL

Pengendalian hipertensi

Pengendalian ketat gula darah pada penderita DM

Modifikasi Faktor Risiko


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Get regular medical checkups.

Control your blood pressure.

Check your cholesterol.

Dont smoke.

Exercise regularly.

Maintain a healthy weight.

Eat a heart-healthy diet.

Manage stress.


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PROGNOSISFAKTOR RESIKO SKOR SKOR RISIKO MORTALITAS

30 HARI (%)

1. Usia 65 74 tahun2. Usia > 75 tahun3. DM/ Hipertensi4. TD < 100 mmHg

5. HR > 100 x6. Klasifikasi Killip II-IV (s3 danatau ronkhi basah, edemaparu, syok kardiogenik)

7. Berat < 67 kg8. Elevasi ST anterior/ LBBB9. Waktu reperfusi > 4 jam

2313

22

111

0 0,8 %1 1,6 %2 2,2%3 4,4 %

4

7,3 %5 12,4 %

6 16,1 %

7

23,4 %

8 26,8 %


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STATUS PASIEN

Rekam Medik

No : 55.85.52 Tanggal : 08 Mei 2013 Hari : Rabu

Nama : Sabam Manurung Umur : 55 tahun

Seks : Lk Pekerjaan : TNI dan Polri

Alamat : Jln. Taduan No 28 Agama : KatolikKec Medan Tembung

l h d


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Keluhan Utama : Nyeri Dada

Ananmnesa :Hal ini telah dialami Os lebih kurang 15 jam yang lalu.Rasasakit menetap hingga dibawa ke RSHAM.Os mengatakan nyeri muncul

setelah berolahraga.Rasa sakit seperti terhimpit benda berat.Os jugamengeluhkan panas di ulu hati.Rasa sakit os menjalar hingga kelengan,bahu dan punggung.Rasa sakit berkurang jika os dalam posisiduduk.Os juga mengeluhkan adanya keringat dingin.Os menyangkaladanya batuk.Os juga mengeluhkan mual dan muntah.Os mengatakan

bahwa nyeri dada ini adalah yang pertama kalinya.Riwayat merokok(+)sejak 24 tahun yang lalu,os merokok 2 bungkus perhari..Riwayathipertensi (-), DM(+).Os juga menyangkal adanya keluarga os yangmengalami keluhan yang sama

Faktor Resiko PJK : Laki laki, Umur > 45 tahun, merokok, DM

Riwayat Penyakit Terdahulu : DM

Riwayat Pemakaian Obat : Tidak Jelas

STATUS PRESENS


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STATUS PRESENS

KU : sedang

Kesadaran : Compos mentis TD : 130/80 mmHg

HR : 85 x/m

RR : 20 x/m

Suhu : 37 C

Sianosis (-) Ortopnu (-) Dispnu (-) Ikterus (-) Edema(-) Pucat (-)


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PEMERIKSAAN FISIK

Kepala : konjungtiva palpebra inferior pucat (-), ikterus (-)

Leher : JVP R+2 cmH2O Dinding toraks : Inspeksi : simetris fusiformis Batas Jantung :

Palpasi : sf ka=ki atas : ICR III

Perkusi : sonor kanan : LSD

kiri : 1 cm lateral LMCS Auskultasi

Jantung : S1 (N) S2 (N) S3 (-) S4 (-) Reguler

Murmur (-) Tipe : PSM, MDM, EJ SM, EDM Grade (-)

Punctum maximum : apeks Radiasi : aksila


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Paru : Suara pernafasan : Vesikuler

Suara Tambahan : Ronki basah basal (-)

Wheezing (-)Abdomen : Palpasi Hepar/Lien: tidak teraba Asites (-)

Ekstremitas : Superior : sianosis (-) clubbing (-)

Inferior : edema (-) pulsasi arteri (+)

Akral : Hangat


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HASIL LABORATORIUM

Darah Lengkap (CBC)

Hb : 14.50 g % RBC: 4570000WBC :13500 Ht 41,5 %

PLT :258000 MCV 93.50 fL

MCH 31.70 pg MCHC 94.90 g%RDW 12.70 % MPV 8.90 fL

PCT 0.24 % PDW 9.4 fL


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HATI

LDH 2053 U/L AST/SGOT 420 U/L

ALT/SGPT 78 U/L

METABOLISME KARBOHIDRATGlukosa Darah (Puasa) 67 mg/dL

Glukosa Darah (Sewaktu) 126 mg /dL

HbA1C 5.9 %

GINJAL

Ureum 95.00 mg/dLKreatinin 2.37 mg/dL

ELEKTROLIT

Natrium (Na)130 mEq/L

Kalium (K) 3.8 mEq/L

Klorida (Cl) 101 mEq/L ENZIM JANTUNG

CK-MB 172 U/L

Diagnosa kerja Fungsional : STEMI Inferior Onset 15 Jam KILLIP I TIMI Risk 3/14


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Fungsional : STEMI Inferior Onset 15 Jam KILLIP I TIMI Risk 3/14 Anatomi : a. coroner Etiologi : aterosklerosisPengobatan : Bed Rest O2 4-6 L/i IVFD Nacl 0,9% 10 gtt/i Loading Plavix 300 mg 1x 75 mg Loading Aspilet 160mg 1 x 80 mg Inj Lavenox 0,13 cc(IV) 0,6 cc /12 jam selama 5 hari Inj Pethidine 25 mg Alprazolam 1 x0,5 mg ISDN 3 x 5 mg Atorvastatin 1 x 40 mg Laxadin syr 3 x c1Rencana pemerikasaan lanjutan :

U/D/F Lengkap AGDA CKMB /Troponin T Ro Thoraks EKGPrognosis : Dubia ad bonam


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Interpretasi EKG: sinus rithym, QRS rate72x/i,QRSdurasi 0,08 PR interval 0,24 p wave(N), ST-T Changes: ST-Elevasi di lead II,III.aVf,

VES(-), LVH (-),Hiperakut T (T-Tall Wave)Kesan: SR + STEMI inferior + First Degree AV

Block


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f k


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Interpretasi foto toraks (AP/PA) :

CTR 52% Ao normal, Po menonjol, Pinggang jantung

normal, Apex downward, kongesti (-), infiltrat(-) Kesan : Mild cardiomegaly

FOLLOW UP


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TERIMA KASIH

Lapkas Pp(STEMI)

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