WHOLE ANTERIOR STEMI WITH ONSET >6 HOURS KILLIP I

Presented by: Rahmah Nurhijjah Supervisor : dr. Muzakkir Amir,Sp.JP,FIHA,FICA

Department of Cardiology and Vascular Medicine Medical Faculty of Hasanuddin University Makassar 2013

PATIENT IDENTITY
Medical Record : 629171 Name : Mr. M Gender : Male Age : 62 years old Date of admission : September 22nd 2013

HISTORY TAKING
Chief Complain : Chest Pain Structural Anamnesis: Occurred since about 7 hours before admitted to the hospital. On the left side the chest pain feels dull heavy pain, it seems to radiates to the back. It does not radiate to the shoulder/arm. Chest pain last for 30 minutes. The pain is not lessen at rest or with medication. Patient had experienced chest pain for a year long.However, patient did not check it to the hospital, because at that time the pain it did not disturb his everyday activities and lessen at rest. The chest pain accompanied with shortness of breath, cold sweat (+), fever (-), cough (-), nausea (+), vomit (+), epigastric pain (-). Defecation and urination normal.

HISTORY TAKING
History of Past Illness:
History of chest pain before (+) No history of heart disease No family history of heart disease No History of diabetes mellitus No history of dyslipidemia No history of asthma No history of epigastric pain

History of cigarette smoking ( - )

History of hypertension (+) since 3 years ago with uncontrolled therapy History of Amlodipin consumption 5 mg 1x1 History of drinking alcohol (-)

PHYSICAL EXAMINATION
General Status Moderate Ilness/ Overweight/Conscious Body Weight :70 kg Body Height :170 cm Body Mass Index : 24,2 kg/m2 Vital Signs BP : 150/100mmHg HR : 96 bpm, regular RR : 28 bpm T : 36,5C

PHYSICAL EXAMINATION
Head and Neck Examinations: Eye : Conjunctiva anemic (-/-), Sclera icteric (-/-) Lip : Cyanosis (-) Neck : JVP R +2 cmHO Chest Examination Inspection Palpation Percussion

: Symmetric between left and right chest. : No mass, no tenderness. : Sonor between left and right chest, lungliver border in ICS IV right anterior . Auscultation : Breath Sounds : Vesicular Adventitious breath sound : Ronchi -/-, wheezing -/-

PHYSICAL EXAMINATION
Cardiac Examination Inspection : Heart apex was not visible Palpation : Heart apex was not palpable Percussion : Dull, left heart border left midclavicular line ICS V. Auscultation : Heart Sounds : S I/II regular, murmur (-) gallop(-)

PHYSICAL EXAMINATION
Abdominal Examination
Insp. Ausc. Palp. Perc. : Flat and following breath movement : Peristaltic sound (+), normal : Liver and spleen is unpalpable : Tympani (+), ascites (-)

Extremities
Oedema : Pretibial -/-, Dorsum pedis -/-

ELECTROCARDIOGRAM (ECG)
ECG :Sinus rhythm, QRS rate 83 bites/ minute, north west axis, PR interval 0,16 s, P wave 0,08 s, QRS comlex 0,08 s, Q patologis III, aVF, V1-V3 ST segment elevation V1-V5 Conclution : sinus rhythm, HR 83 bite/minute, whole anterior acute myocard infraction , old myocard infraction inferior

ELECTROCARDIOGRAM (ECG)
ECG :Sinus rhythm, QRS rate 93 bites/ minute, right axis devilation, PR interval 0,12 s, P wave 0,08 s, QRS comlex 0,08 s, Q patologis in III, aVF, V1-V3 ST segment elevation in V1-V5 Conclution : sinus rhythm, HR 93 bite/minute, whole anterior acute myocard infraction , old myocard infraction inferior

Laboratorium Finding
Complete blood count
Test WBC RBC HGB HCT PLT Result 9,05 x 103/ul 4.86 x 106/l 15.0 gr/dl 44,6 % 141 x 103 /l Normal value 4.0 10.0 x 103 4.0 6.0 x 106 12 16 37 48 150 400 x 103

Blood Chemistry
Test GDS Ureum Creatinine SGOT SGPT Total Chol HDL Chol LDL Chol Result 141 mg/dl 33mg/dl 0,9 mgr/dl 24u/l 21 u/l 123 mg/dl 23mg/dl 99 mg/dl Normal value <140 10 50 < 1.3 <38 <41 <200 > 55 < 130

Cardiac Enzymes
Test CK CK-MB Troponin-T Result 211U/L 10 U/L <0.02 Normal value <190 <25 <0,05

Electrolyte
Test Result Normal value

Na
K Cl

145 mmol/l
3.5 mmol/l 110 mmol/l

136-145
3.5-5.1 97-111

CHEST X-RAYS
Cloudy parahilar accompanied with cardiovascular suprahilar dilatation on both lungs There is no specific active process seen on both lungs Cor CTI widen 0,57 cm, aorta dilated and calcified Both sinuses and diaphragma in good condition Bones intact Impression: Cardiomegaly with signs of Pulmonary edema dilatation et atherosclerosis aorta

WORKING DIAGNOSIS
1. ST elevation myocardial infarction (STEMI) whole anterior onset >6 hours KILLIP I, 2. Old myocard infraction inferior 3. Grade I hypertension

MANAGEMENT
O2 2 -4 Lpm IVFD NaCl 0,9% 10 drops/min Aspilet 80 mg 0-1-0 Aspirin (Antiplatelet) Plavix 75 mg 0-0-1 Clopidogrel (Antiplatelet) Injection ISDN 0,5 mg/hours/SP Nitrat Captopril 25 mg 1-1-1 ACE-Inhibitor Simvastatin 20 mg 0-0-1 Statin (Anticholesterol) Alprazolam 0,5 mg 0-0-1 Antianxietas Laxadyn syr 0-0-2 c

PLANNING
Coronary angiography

ST ELEVATION MYOCARDIAL INFARCTION

DEFINITION
Myocardial infarction (MI) rapid development of myocardial necrosis caused by a critical imbalance between the oxygen supply and demand of the myocardium. This usually results from plaque rupture with thrombus formation in a coronary vessels, resulting in an acute reduction of blood supply to a portion of the myocardium.

PATHOPHYSIOLOGY
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.

PATHOGENESIS
Lipid transport disorder Inflamation Plaque deposition

Stable plaque
Thrombus

Erosion

Plaque rupture

Acute coronary syndrome: Unstable angina Myocardial infarction : - Non Q waves - Q waves

Stable angina pectoris

Thrombosis

RISK FACTOR
Non- Modifiable
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

Modifiable
Smoking
Hypertension Diabetes Mellitus Dyslipidemia Obesity Lack of physical activity

age 65 in mother or sister

CLINICAL MANIFESTASION
Prolonged pain (usually >20 minutes) constricting, crushing, squeezing

Usually retrosternal location,

radiating to left chest, left arm; can be epigastric Dyspnea Diaphoresis Palpitations Nausea/vomiting

WHO DIAGNOSTIC CRITERIA

1. Clinical history of ischemic type chest pain lasting >20 minutes 2. Changes in serial ECG tracings 3. Rise and fall of serum cardiac biomarkers such as creatinine kinaseMB fraction and troponin

ECG CHANGES
Timing of myocardial infarction based on ECG

SERUM CARDIAC MARKER ELEVATIONS

Troponin T
CK-MB CK

Myoglobin

SGOT

DIAGNOSIS
Signs of myocardial ischemia ECG

Yes
ST segmen elevation ?

Acute Myocardial Infarction ( Q-wave, non-Q wave )

STEMI

No

Lab

Yes

Biochemical cardiac markers ?

NSTEMI (No ST-Segment Elevation Myocardial Infarction)

No

Unstable Angina

INITIAL TREATMENT
1. 2. 3. 4. Bed Rest Diet Oxygen (2-4L/mnt) Anti platelet therapy :
Aspirin 160-325 mg chewed immediately and 81-162 mg continued indefinitely. Clopidogrel 300-600 mg loading dose and 75 mg daily continued for at least 14 days and up to 12 months

5. Nitroglycerin ISDN 10 mg or 20 mg, 2-3 a day. ISDN 5 mg SL when chest pain.

INITIAL TREATMENT
6. Morphine 2,5-5 mg or pethidin 12,5-25 mg iv 7. ACE I (Captopril 12,5-25 mg ) 8. Fibrinolytic therapy: a) Streptokinase 1.5million units iv b) Tenecteplase 0.5mg/kg body weight iv. 9. Anticoagulation therapy: a) Low Molecular Weight Heparins ( Fondaparinux) 2.5mg/24hrs/sc for up to 8 days post-MI. 10. Statins Simvastatin 20 mg

PROGNOSIS KILLIP CLASSIFICATION

Clas s I
II III IV Description No clinical signs of heart failure Rales or crackles in the lungs, an S3, and elevated jugular venous pressure Acute pulmonary edema Cardiogenic shock or hypotension (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction

Mortality Rate (%) 6

17 30 - 40 60 80

PROGNOSIS TIMI SCORE

Historical
Age 65-74 >/= 75 DM/HTN or Angina Exam 2 points 3 points 1 point

Total Score
0 1 2 3 4 5 6 7 8 9-14

Risk of Death in 30 days 0.8% 1.6% 2.2% 4.4% 7.3% 12.4% 16.1% 23.4% 26.8% 35.9%

SBP < 100

HR > 100 Killip II-IV Weight > 67 kg

3 points
2 points 2 points 1 point 1 point 1 point (0-14)

Presentation
Anterior STE or LBBB Time to treatment > 4 hrs Risk Score = Total

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