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Anterolateral wall ST ElevationMyocard Infarction (STEMI) , ONSET>12 H ,KILLIP II
BY:Muh. Kemal Putra
C 111 07 096
SUPERVISOR:
Dr. Khalid Saleh, Sp.Pd
DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK
BAGIAN KARDIOLOGY
FAKULTAS KEDOKTERAN
UNIVERSITAS HASANUDDIN
MAKASSAR
2012
CASE PRESENTATION
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PATIENT IDENTITY
Name : Mr. N
Gender : Male
Age : 52 years old
Address : Sidrap
Registration no. : 554712
Date of admission : 19th June 2012
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ANAMNESIS
Chief complain : Chest pain
History of present illness :
His chest pain begin + 1 day prior to admission at Wahidin
Sudirohusodo hospital. The pain is felt at the substernal area,
with continuous, stabbing sensation spreading to the back
accompanied with cold sweat. Pain does not subside with rest.
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ANAMNESIS
Nausea ( - ), vomiting ( - )
Cough ( - ), Shortness of breath ( - ), Palpitation ( - )
Dizziness ( - ), Headache ( - ) , Fever ( - )
Urination = normal
Defecation = normal
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ANAMNESIS
HISTORY OF PREVIOUS ILLNESS
History of heart disease ( - )
History of hypertension is ( - )
History of diabetes melitus ( - )
History of dyslipidemia is unknown
History of smoking ( - )
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PHYSICAL EXAMINATION
General appearance : Moderate illness/well nourished/
composmentis
Vital Signs:
BP : 110/70 mmHg RR : 26 x/min
HR : 76x/min T : 36,8 (afebris)
Head :Anemia ( - ) , Icterus ( - )
Neck : JVP R+2cm H20
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PHYSICAL EXAMINATION
Lung : Bronchovesicular, Rhonchi +/+ basal , Wheezing -/-
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
A : Heart Sound I/II pure regular, murmur(-)
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PHYSICAL EXAMINATION
Abdomen :
Inspection : flat and following breath movement
Auscultation : peristaltic sound (+) , normal
Palpation : liver and spleen unpalpable
Percussion : tympani, ascites (-)
Extremities : Edema -/-
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ECG FINDINGS
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ECG INTERPRETATION
Sinus Rhythm
QRS Rate : 90 x/minutes
P Wave : 0.08
PR interval : 0.16
QRS complex : 0.08
Axis : +65
ST segment : ST elevation V3-V5, I, aVL,
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Rhythm Sinus
Heart rate 90 x/ minute
Anterolateral Myocardial Infarction
ECG CONCLUSION
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ECHOCARDIOGRAPHY
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ECHOCARDIOGRAPHY
CONCLUSION :
LV systolic & dystolic dysfunction, EF 46%
Dilated LA, LVH (+)
MV prolaps
Hypokinetic inferolateral septal
PH-TR severe
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CHEST X-RAY
CONCLUSION :
Cardiomegaly and pulmonary edema
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Complete blood count
WBC :17.93x103/ul
RBC : 5.95X10^6/ul
HGB : 16.6 gr/dl
HCT : 51.9%
PLT : 271 x 103/l
Enzymes
CK : 4118 U/L
CK-MB : 319 U/L
Trop T : >2.0
Blood chemistry
Blood glucose :138
Ureum : 26 mg/dl
Creatinine : 1.0 mg/dl
SGOT : 407 u/dl
SGPT : 87 u/ dl
Total Cholesterol : 236 u/dl
HDL : 137 u/dl
LDL : 44 u/dl
Trigliseride : 209 u/dl
LABORATORIUM FINDINGS
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DIAGNOSIS
Anterolateral wall STEMI onset >12 hours, Killip II
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INITIAL MANAGEMENT
Bed rest
O2 2-4 lpm ( via nasal canule )
IVFD NaCl 0,9% 10 dpm
Cedocard 10mg/ min/iv/SP
Amiodarone 600mg/24 hrs/SP
Arixtra 2,5mg/24hrs/SC
Fargoxin 0,5mg/iv/bolus(slowly)
CPG 75 mg 0-1-0/ oral
Aspilet 80 mg 1-0-0/oral
Captopril 6.25mg 1-1-1
Simvastatin 20mg 0-0-1
Alprazolam 0.5mg 0-0-1/ oral
Laxadyne syr 0-0-2tbsp / oral
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ADVISE
Coronary Angiography
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DISCUSSION
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DEFINITION
Myocardial infarction (MI) rapid
development of myocardial necrosis
caused by a critical imbalance
between the oxygen supply anddemand of the myocardium.
This usually results from plaquerupture with thrombus formation in
a coronary vessels, resulting in an
acute reduction of blood supply to a
portion of the myocardium.
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PaTHOPHYSIOLOGY
Occurs when coronaryblood flow decreasesabruptly after athrombotic occlusion of
a coronary arterypreviously affected byatherosclerosis.
In most cases,infarction occurs whenan atheroscleroticplaque fissures,ruptures, or ulcerates.
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CLASSIFICATION
ACS describe a group of conditions resulting from acute myocardial
ischemia (insufficient blood flow to heart muscle) ranging from
unstable angina to myocardial infarction.
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Gender and Age
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
Risk factors
Non- Modifiable Modifiable
Smoking
Hypertension
Diabetis Mellitus
Dyslipidemia
Obesity
Lack of physical activity
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WHO DIAGNOSTIC CRITERIA
1. Clinical history of ischaemic type chest pain lasting
>20 minutes
2. Changes in serial ECG tracings
3. Rise of serum cardiac biomarkers such as
creatinine kinase-MB fraction and troponin-T
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CLINICAL FEATURES
Chest pain, >30 minutes
Usually tight, crushing, and band
likeLocation in retrosternal
May radiate to left arm, throat, and
jawAssociated features includingpalpitation, sweating,
breathlessness, and nausea.
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ECS CHANGES IN AMI
ST segment elevation
over area of damage
ST depression in leadsopposite infarction
Pathological Q waves
Reduced R waves
Inverted T waves
w v
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Leads with st elevation in
mi
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Cardiac biomarkers
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DIAGNOSIS
No
Yes
YesNo
Acute Myocardial Infarction
( Q-wave, non-Q wave )
NSTEMI( No ST-Segment
ElevationMyocardial Infarction )
Unstable Angina
Signs of myocardial
ischemia
ST segmen elevation ?
Biochemical cardiac markers ?
Diagnose
ECG
Lab
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Manage chest pain and bad feeling/stress
Oxygen 4 lpm ( increase the supply of oxygen)
Give nitrat oral/IV (for the angina)
Give antiplatelet
Give morphine or petidine (for infark pain)
Give diazepam 2/5mg (for make the patient relax)
Therapy
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Hemodanamic stabilization
Fasting first 8 hours after attack then eat soft food
Give laxadyn
Bed rest until 24 hours free from angina
Blood pressure and heart rate is control with
-Beta blocker
-Ace inhibitor
Therapy
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Myocardiac reprofusion as soon as possible
Thrombolitic - streptokinase and t-PA
Plaque stabilization
Simvastatin
Therapy
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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, and
elevated jugular venous pressure
17
III Acute pulmonary edema 30 - 40
IV Cardiogenic shock or hypotension
(systolic BP < 90 mmHg), and evidence
of peripheral vasoconstriction
60 80
KILLIP CLASSIFICATION
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COMPLICATION
Congestive heart failure
Myocardial rupture
Arrhythmia
Pericarditis
Cardiogenic shock
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RISK SCORE FOR ACS
TIMI Risk Score for STEMIHistorical
Age 65-74
>/= 75
2 points
3 points
DM/HTN or Angina 1 point
Exam
SBP < 100 3 pointsHR > 100 2 points
Killip II-IV 2 points
Weight < 67 kg 1 point
Presentation
Anterior STE or
LBBB
1 point
Time to rx > 4 hrs 1 point
Risk Score = Total (0-14)
Risk Score Odds of death by
30D*
0 0.1 (0.1-0.2)
1 0.3 (0.2-0.3)
2 0.4 (0.3-0.5)
3 0.7 (0.6-0.9)
4 1.2 (1.0-1.5)
5 2.2 (1.9-2.6)
6 3.0 (2.5-3.6)
7 4.8 (3.8-6.1)
8 5.8 (4.2-7.8)
>8 8.8 (6.3-12)
* referenced to average mortality (95%
confidence intervals)
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RISK SCORE FOR ACSTIMI RISK SCORE FOR NSTEMI/UA
Historical
Age 65 years
Presence of at least three risk
factors for CAD
Known coronary stenosis of 50 % Use of aspirin in past seven days
Presentation
Recent ( 0.5mm
Calculated
TIMI RiskScore
Risk of >1
Primary EndPoint* in
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