Stemi (ST-elevaTION myocardial infarCT)

DIAN WAHYUNI(C111 09 348)

Supervisor : Prof. Dr. dr. ALI ASPAR M, SpPD. SpJP(K), FIHA, FAsCC, FINASIM, FICA

C A S E P R E S E N TAT I O N

Department of Cardiology and Vascular Medicine Medical Faculty of Hasanuddin University

Makassar 2014

Patient Identity• Name : Mr. M• Age : 72 years old• Gender : Male• Address : jl. Emisaelan 3 no.22• MR : 653885• Day of Admission : March 06

2014

Chief Complaint : Chest Pain

It was felt since 20 hours ago before admit to the hospital. The pain was felt > 30 minute and the discomfort radiated to the shoulder, down the left arm and to the back. The pain didn’t infleunce by activity. Cold sweat (+), palpitation (+), headache (-) Cough (-) dyspneu (+) Nausea (-), vomiting (-), epigastric pain (-), defecation not yet since the onset of chest pain, normal urination. DOE (-), PND (-), orthopneu (-), DM (-), HT (-).

HISTORY TAKING

Past Medical History• History of chest pain (-)• History of heart disease (-)• History of DM (-)• History of smoking (+)

1box/3day since 20 years ago.• History of hypertension (-)

Family History• History of heart disease in

family (-)

RISK FACTORS

ModifieddNon- Modified

• Gender : Male

• Age 72 years old

History of smokingLow HDL < 40

General Status• Moderate illness/ Well nourished/ Conscious• Nutritional Status: normal

– Weight : 68 kg– Height : 170 cm– BMI : 23.5 kg/m2

Vital Sign• Blood Pressure : 130/80 mmHg• Pulse Rate : 68 bpm• Respiratory Rate : 24 bpm• Temperature : 36.5 0C (axilla)

PHYSICAL EXAMINATION

• Eye : Conjunctiva anemic (-/-),Sclera icteric (-/-)

• Lip : Cyanosis (-)• Neck : JVP R+0 cmH20

Head and Neck

Examination

•Inspection : Symmetric between left and right chest.•Palpation : No mass, no tenderness.•Percussion : Sonor between left and right chest, lung-liver border in ICS IV right anterior.•Auscultation: Respiratory sound: Vesicular •Additional sound : Ronchi -/-, Wheezing -/-

Thorax Examina

tion

Heart examination :– Inspection : apex invisible– Palpation : apex impalpable– Percussion : upper heart : ICS II parasternalis linea sinistra

bottom heart : ICS IV parasternalis linea dextra left Heart : ICS IV midclavicularis linea sinistra right heart : ICS IV parasternalis linea dextra

– Auscultation : heart sound I/II regular, murmur (-), gallop (-)

•Inspection : flat, following breath movement•Auscultation : peristaltic (+) normal •Palpation : mass (-), pain (-), liver and lien impalpable•Percussion : tymphani (+), ascites (-)

Abdomen examinati

on

•Pretibial oedema -/-

Extremities examinatio

n

Electrocardiogram (ECG) 7/3/2014

ECG interpretationRhythm : Sinus rhythmHeart rate : 75 bpmRegularity : regulerAxis : Normoaxis -25 degreeP wave : 0,08 sPR interval : 0,16 sQ pathologist : -QRS complex : Duration 0,06 sST Segment : ST elevation lead v1, v2 and v3 T inverted : -Conclution : SR, HR 75 x/minute, normoaxis, acute

anteroseptal myocardial infarction

Radiology findings• Cardiomegaly with

dilatiatio et elongatio aortae.

• Diaphragm elavation dextra (intrahepatic process ?? )

LABORATORIUMHEMATOLOGY RESULT NORMAL

VALUE

UNIT

WBC 7.7 4,00-10,0 (10³/UI)

RBC 4,421 4,00-6,00 (106/UI)

HGB 12.41 12,0-16,0 (gr/dL)

HCT 37.8 37,0-48,0 (%)

PLT 192 150-400 (103/uL)

GDS 133 140 Mg/dL

Uric acid 6.0 3,4-7.0 Mg/Dl

Creatinin 1,2 <1,3 Mg/dL

6-7/3/2014

Na 132 136-145 mmol/L

SGOT 39 <38 mmol/L

SGPT 26 <41 Mg/dL

PT 11.4 10-14 detik

APTT 23.2 22-30 detik

CK 157 L<190,P<187 u/L

CKMB 23.3 <25 u/L

TROPONIN T 2.0 <0.05

HDL 21 >55

LDL 118 <130

Working DIAGNOSIS

STEMI ANTEROSEPTAL ONSET > 24 hour KILLIP I

MANAGEMENT Bed rest Oxygen 4 lpm via

nasal canule IVFD NaCl 0.9% 500

cc/24 hr Nitrat Cedocard 2 mg/hr/SP Antiplatelet Clopidogrel 300 mg loading dose -> 1 X 75 mg Aspilet 160 mg loading dose -> 1 x 80 mg

Anticoagulant Arixtra 2,5 mg/24 hr/SC 3-8 day LaxativeLaxadyne syr 0-0-II cth Statin Simvastatin 1x20 mg Anti-anxietyAlprazolam 0,5 mg 0-0-1 ACE-Inhibitor

Captopril 2x6,25 mg

DISCUSSION

STEMI (ST-ELEVATION MYOCARDIAL INFARCT)

Imbalance in oxygen supply and demand, which is most often caused by plaque rupture with thrombus formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of

the myocardium.

DEFINITION

Is an irreversible necrosis of heart muscle due to prolonged ischemia, which is suddenly happened.

Acute

myocardial

infarction

RISK FACTORS

Modifiable Non ModifiableoSmokingoHypertensionoObesityoDiabetes MellitusoDyslipidemia-Low HDL < 40-Elevated LDL/ TG

oGender and age: -male after age 45 y.o -female after age 55 y.ooFamily Historyin first degree relative > 55 y.o for Male / 65 y.o for female

WHO Diagnostic Criteria1. Clinical history of ischaemic type

chest pain2. Changes in serial ECG tracings3. Rise of serum cardiac biomarkers

such as creatinine kinase-MB fraction and troponin-T

Clinical Features

PathophysiologySTEMI generally occurs when coronary blood flow

decreases abruptly after a thrombotic occlusion of a coronary artery previously affected by atherosclerosis.

In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates and when conditions favor thrombogenesis

Histological studies indicate that the coronary plaques prone to rupture are those with a rich lipid core and a thin fibrous cap.

MANAGEMENTTreating Chest Pain and Stress: • O2 2-4 LPM• Isosorbid dinitrate 5 mg SL• Low dose aspirin (Aspilet) 80 mg loading 2 tab

160mg• Clopidogrel 75 mg, loading 4 tab 300 mg• Diazepam 2-5 mg / 8 hours

Hemodinamic Stabilization• Fasting first 8 hours after attack, soft food• Laxadyn• Bed rest until 24 hours free from angina• Cardioselective Beta Blocker Bisoprolol

(do not use if hypotension or Bradicardia)• Ace Inhibitor

Myocardial Reperfusion• Thrombolytic effective with onset < 12 hours

– Streptokinase (streptase) 1,5 million unit soluted in 100 ml Nacl O,9%– Anti coagulant low molecular weight heparin

• Fondaparinux (Arixtra)

Plaque Stabilization Simvastatin

TIMI risk score for STEMI for predicting 30-day mortality.

Morrow D A et al. Circulation. 2000;102:2031-2037

Copyright © American Heart Association, Inc. All rights reserved.

KILLIP ClassificationClass Definition Mortality %

I No sign of Heart Failure 6

II + S3 and/or ronchi and

elevated of Jugular

venous pressure

17

III Pulmonary Oedema 30-40

IV Cardiogenic shock 60-80

THANK YOU