ST Elevation Myocardial Infarction (STEMI) Inferior Onset 7 hours, KILLIP I

By: Livia Sagita Ruslim

Supervisor : dr. Pendrik Tandean, Sp PD-KKV. FINASIM

PATIENT IDENTITY
Name Gender Age Address Registration no. Date of admission : Mr. AR : Male : 54 years old : Perintis Kemerdekaan street, Makassar : 618014 : 08th July 2013

ANAMNESIS
Chief Complaint : Chest pain Present Illness History :

The chest pain began for + 7 hours before he was admitted to Wahidin Sudirohusodo hospital, occurred when he was cleaning

a post. The pain is described like dull heavy feeling on the chest,
continuously, did not radiate to back and left arm and the pain not improved by resting. The chest pain accompanied with

dizziness and cold sweating a lot.

ANAMNESIS
Nausea (-), vomiting (-) Cough ( - ), Shortness of breath ( - ), Fever (-) Dyspnea on effort (-), Paroxysmal nocturnal dyspnea(-) Urination normal Defecation normal

ANAMNESIS
Previous Illness History
History of heart disease ( - )

History of hypertension (-)

History of diabetes melitus (-) History of dyslipidemia (-)

ANAMNESIS
Personal History Smoking (+) 2 packs/ day for 30 years Alcohol (+) 3L/ day for 10 years STOP

Family History
Father () old aged Mother () old aged

ANAMNESIS
RISK FACTOR
Modified Risk Factor
History of smoking (2 packs of cigarette/day for 30 years)

Non-modified risk factor:

Gender : male Age : 54 year old

PHYSICAL EXAMINATION
General appearance : Moderate illness/well nourished/

composmentis
Vital Signs:

BP : 110/70 mmHg HR : 84x/min

RR : 22 x/min T : 36,6C

BW : 97kg H : 173cm

Head : Anemia (-) , Icterus (), Palpebra Edema (-)

Neck : JVP R+0 cmH20

Lung : Vesikuler Rhonchi -/- Wheezing -/-

PHYSICAL EXAMINATION
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 - Lower border : left 5th ICS A : Heart Sound I/II pure regular, murmur(-)

PHYSICAL EXAMINATION
Abdomen :

Inspection Auscultation Palpation Percussion

: symmetrical big and following breath movement : peristaltic sound (+) , normal : liver and spleen unpalpable, mass (-) : tympani, ascites (-)

Extremities : Edema -/-

CHEST X-RAY (9th July 2013)

Cor : expand with CTI:

0.59, waist of heart concaved, apex lifted (RVE), aorta dilatation with aorta dilatation.

Result : Cardiomegaly
a
b c

ECG FINDINGS

ECG INTERPRETATION
Rhythm Frequency

: AV Block : 45 x/ minute

Axis
P Wave PR Interval

: Normoaxis
: 0.08s : 0.36s

QRS Complex : 0.06s ST Segment T Wave

: ST Segments Elevation in leads II, III, aVF : T wave inverted in leads III : Inferior Acute Myocardial Infarction, AV Block 1st degree

Conclusion

EChocardiography

LV systolic function decreased --- EF 33.90%

LVH (+) --- IVSd 17.7mm

LABORATORIUM FINDINGS
Complete blood count
WBC : 10.86 x 103/ul RBC HGB HCT PLT

Blood chemistry
Ureum
Creatinine SGOT SGPT GDS

: 42 mg/dl : 1.6 mg/dl : 37 u/dl : 14 u/ dl : 120 mg / dl

: 4.92 x 106/uL : 11.7 gr/dl : 34.8% : 261 x 103/l

Enzymes
CK

: 603 U/L

Uric acid

Trop T : 0.34

Coagulation Time
PT

: 11.6s

: 6.5 mg / dl Cholesterol total : 188 mg/dl HDL : 32 mg / dl LDL : 138 mg / dl Triglyceride : 159mg / dl

APTT : 24.5s

DIAGNOSIS
STEMI Inferior onset 7 hours, Killip I AV Block 1st degree

INITIAL MANAGEMENT
Bed rest O2 2-4 lpm ( via nasal canule ) IVFD NaCl 0,9% 500cc/24 jam Streptokinase 1.5million U / iv Arixtra 2.5mg/24hrs/sc Aspilet 162 mg qd (chewed) loading dose Clopidogrel (Plavix) 4x75 mg qd loading dose

Simvastatin 20 mg qd

Laxadin syr 1x2cth

ADVISE
Coronary Angiography

ACUTE CORONARY SYndrome

DEFINITION
Acute coronary syndromes (ACS) is the clinical

manifestation of the critical phase of coronary artery disease.

Based on ECG and biochemical markers it is

distinguished from :

1)ST elevation myocardial infarction (STEMI) 2)Non-ST elevation myocardial infarction

(NSTEMI)
3)Unstable Angina

PATHOPHYSIOLOGY

4
American Heart Association: http://watchlearnlive.heart.org

PATHOPHYSIOLOGY

Risk factors
Non-Modifiable
Gender and age.
Men, older than age 45
Women, older than age 55

Modifiable
Smoking Hypertension Diabetes Mellitus Dyslipidemia

Family history
Anyone with a 1st degree

Obesity
A desentary lifestyle Stress

male or female relative who developed CAD before age 55 or 65.

Overbaugh KJ. Acute Coronary Syndrome. AJN. May 2009: 109 (5):43

ACUTE CORONARY SYNDROME

Daga LC, Kaul U, Mansoor A. Approach to STEMI and NSTEMI. Supplement to JAPI. 2011 (59):19.

Differences

Unstable Angina Thrombus partially or intermittently occludes the coronary a. chest pain with/without radiation to arm, neck, back or epigastric region Shortness of breath, diaphoresis, nausea, lightheadedness, tachycardia, tachypnea, hypotension/ hypertension, SaO2 and rhythm abnormalities Occurs at rest or with exertion; limits activity

NSTEMI Thrombus partially or intermittently occludes the coronary a. chest pain with/without radiation to arm, neck, back or epigastric region Shortness of breath, diaphoresis, nausea, lightheadedness, tachycardia, tachypnea, hypotension/ hypertension, SaO2 and rhythm abnormalities Occurs at rest or with exertion; limits activity Longer in duration and more severe than in UA

STEMI Thrombus fully occludes the coronary a. chest pain with/without radiation to arm, neck, back or epigastric region Shortness of breath, diaphoresis, nausea, lightheadedness, tachycardia, tachypnea, hypotension/ hypertension, SaO2 and rhythm abnormalities Occurs at rest or with exertion; limits activity Longer in duration and more severe than in UA (infarction occurs if perfusion is not restored) ST-segment elevation or new LBBB on ECG Cardiac biomarkers are elevated O2 to maintain SaO2 level >90% Nitroglycerin or morphine to control pain -blockers, angiotensinconverting enzyme inhibitors, statins, clopidogrel, LMWH PCI within 90 minutes of medical evaluation Fibrinolytic therapy within 30 minutes of medical evaluation

Cause Signs and symptoms

Diagnostic Findings

ST-segment depression or T-wave inversion on ECG Cardiac biomarkers not elevated

ST-segment depression or T-wave inversion on ECG Cardiac biomarkers are elevated

Treatment

O2 to maintain SaO2 level >90% Nitroglycerin or morphine to control pain -blockers, angiotensinconverting enzyme inhibitors, statins, c`lopidogrel, LMWH, and glycoprotein Iib/IIIa inhibitors

Anderson JL, et al. Circulation 2007;116(7):e148-e304; Hazinski MF, et al., editors. Handbook of emergency cardiovascular care for healthcare providers. Dallas:American Heart Association; 2008.

O2 to maintain SaO2 level >90% Nitroglycerin or morphine to control pain -blockers, angiotensinconverting enzyme inhibitors, statins, clopidogrel, LMWH, and glycoprotein Iib/IIIa inhibitors Cardiac catheterization and possible PCI for patients with ongoing chest pain, hemodynamic instability, or increased risk of worsening clinical condition

RISK SCORE FOR ACS

TIMI Risk Score for STEMI Historical Age 65-74 2 points 75 3 points DM/HTN or 1 point Angina Exam SBP < 100 3 points HR > 100 2 points Killip II-IV 2 points Weight < 67 kg 1 point Presentation Anterior STE or 1 point LBBB Time to rx > 4 hrs 1 point TIMI Risk Score for NSTEMI Historical Age 65 3 risk factors for CAD Known CAD (Stenosis 50%) Aspirin use in past 7 days Presentation 2 anginal events in <24hrs ST-segment deviation 0.5mm cardiac markers Risk Score = Total Points 1 1 1 7 1 1 1 1

Risk Score = Total

(0-14)
Daga LC, Kaul U, Mansoor A. Approach to STEMI and NSTEMI. Supplement to JAPI. 2011 (59):20.

Management

Initial Treatment
1. Bed Rest 2. Diet 3. Oxygen (2-4L/mnt) 4. Anti platelet therapy :

- Aspirin 162-325mg chewed immediately and 81-162 mg continued indefinitely. - Clopidogrel 300-600mg loading dose and 75mg daily continued for at least 14 days and up to 12 months.

5. Nitroglycerin
0.4 mg SL tablets every 3-5 min up to 3 times; if effect is not sustained, can continue with an IV drip of 50mg in 250mL Dextrose 5%.
2013 ACC/AHA Guideline STEMI

Initial Treatment
6. Morphine 2-5mg iv Q5-30min 7. Fibrinolytic therapy:

a) Streptokinase 1.5million units iv b) Tenecteplase 0.5mg/kg body weight iv

8. Anticoagulation therapy:

a) Low Molecular Weight Heparins ( Fondaparinux) 2.5mg/24hrs/sc for up to 8 days post-MI.

9. Statins

Simvastatin 20mg qd

Options for Transport of Patients With STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis: Door-to-Needle within 30 min.

Not PCI capable

Onset of symptoms of STEMI 9-1-1 EMS Dispatch

EMS on-scene
Encourage 12-lead ECGs. Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min.

InterHospital Transfer

5 8 EMS Transport min. min. EMS transport Patient EMS Prehospital EMS-to-balloon within 90 min. fibrinolysis Patient self-transport EMS-to-needle Hospital door-to-balloon within 30 min. within 90 min.
Golden Hour = first 60 min. Total ischemic time: within 120 min.

GOALS

PCI capable

Antman EM, et al. J Am Coll Cardiol 2008. Published ahead of print on December ; ACC/AHA STEMI Guideline 2009

PROGNOSIS
KILLIP CLASSIFICATION

Class I

Description No clinical signs of heart failure

Mortality Rate (%) 6

II

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

17

III IV

30 - 40 60 80

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