ST SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI)

INFERIOR ONSET > 24 HOURS, KILLIP 1,TIMI SCORE 2/14 (2,2%)

PRESENTED BY : NUR HALIMATUSSANIAH C111 09 849 SUPERVISED BY : DR PENDRIK TANDEAN, Sp PDKKV, FINASIM
KEPANITERAAN KLINIK BAGIAN KARDIOVAKULER UNIVERSITAS HASANUDDIN MAKASSAR 2013

PATIENT IDENTITY
MR number NAME : 636103 : MR A

AGE

: 47 years old

DATE OF ADMISSION: 7TH November 2013

HISTORY TAKING
Chief complaint: Chest pain Occurred 3 days before admitted, At the beginning, the chestpain was like being sliced, burned, the pain was radiated from the chest till the jaw The pain occur while the patient carry boxes of paper. Duration of chest pain is about an hour and did not relieved by rest. Patient have been admitted in RS Pare-pare before he been refferred to RSWS.

Shortness of breath (-) , sweating (+), weakness (-), and nausea (-),
Cough (-), fever (-) Proxymal Nocturnal Dyspneu (-), Dyspneu On Effort (+), Ortopneu (-)

Defecation and urination : normal

HISTORY OF PAST ILLNESS

History of hypertension ( + ) since 3 years ago with uncontrolled

therapy
History of Osteorthritis (+) 2 years ago History of diabetes mellitus (-) History of family with CVD ( - ) History of smoking (+) 1 year ago, 2 packet daily

History of heart disease (-)

History of family with heart disease (-) History of asthma (-) History of gastritis (-)

RISK FACTORS

Modifiable
- Hypertension (+) - Tobacco use (+)

Non Modifiable
Gender : Male

PHYSICAL EXAMINATION

Vital sign
General status
Moderate illness/well nourished/conscious
BP: 170 / 90 mmHg HR: 70 x/min RR: 18 x/min T : 36.50 C

REGIONAL STATUS
Head Examination Eyes : anemia (-), icterus (-) Lip : cyanosis (-) Neck : lymphadenopathy (-), JVP R +0 cmH2O Thoracal Examination Inspection : symetric, normochest Palpation : mass (-), tenderness (-), VF R=L Percussion : sonor Auscultation : breath sound : bronchovesicular, ronchi -/-, wheezing -/-

REGIONAL STATUS
Heart Examination Inspection : IC wasnt visible Palpation : IC wasnt palpable Percussion : normal heart size Upper border : left 2nd ICS Lower border : left 5th ICS Right border : right parasternalis line Left border : left medioclavicular line Auscultation : Regular of I/II heart sound, murmur (-)

Abdominal Examination Inspection : flat and following breath movement Auscultation : peristaltic sound (+) , normal Palpation : liver and spleen unpalpable Percussion : tympani, ascites (-) Extremities Oedema : pretibial (-), dorsum pedis (-)

Electrocardiography (ECG)

INTERPRETATION
Rhythm : Sinus Heart rate : 56 bpm Regularity : reguler Axis : Normoaxis, 20o QRS duration : 0.92 s PR interval : 0.12s P wave : 1.08s ST Segment : T inverted at lead II,III, AVF Conclusion : Possible Inferior myocardial infarction, probably old summary

ECHOCARDIOGRAPHY 7/11/2013

DESCRIPTION OF WALL MOTION, MASSES, VALVES, PERICARDIUM

LV systolic function, EF 67% Dimension of Cardiac compartment : normal LVH: (-) Hipokinetic of inferior base + inferoseptl RV systolic function is good, TAPSE : 1.8cm Cardiac valve : - Mitral : function and movement good - Aorta : 3 cuspis, calcification (-), function & movement normal - Tricuspid : function & movement normal - Pulmonal :function & movement normal - E/A > 1 (Pseudonormal) - Conclusion :LV diastolic dysfunction, EF 67%, Hipokinetic of inferior base + inferoseptl e.c CAD

LABORATORY EXAMINATION
WBC : 8.11 x 103 HGB : 14.3 g/dl HCT : 42.9 % RBC : 4.73 x 106 /mm3 PLT : 247x 103 /mm3 Cardiac enzyme CK : 1393 u/L CK MB : 19 u/L Troponin T : 0,33 u/L Electrolyte Sodium :143 mmol/l Potassium : 4.4 mmol/l Chloride : 108 mmol/l

Random blood sugar: 106 mg/dl SGOT : 71 u/l SGPT : 35 u/l Ureum : 28 Creatinin : 0.7 PT : 9,9 APTT : 24,4 Total Cholesterol : 212mg/dl HDL : 35 mg/dl LDL : 176 mg/dl Triglyseride : 187 mg/dl

Complete blood

Blood chemistry

WORKING DIAGNOSIS
STEMI Inferior onset 1 hour, KILLIP I

MANAGEMENT
O2 2 LPM (via nasal canule) Cardiac Diet IVFD NaCl 0,9% loading 500 cc/24 hours Vasodilator Cedocard 0.5mg/hour via SP Anti Platelet Aggregation ASA (Aspilet) 2 x 80 mg Clopidogrel (Plavix) 4 x 75 mg ACEI Captopril 3 x 12,5mg Anti cholesterol HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg) Anxiolytic Benzodiazepin (Alprazolam) 0,5 mg 0- 0 - 1 Laxative Laxadin syrup 1 x 2 cth

DISCUSSION

ACUTE CORONARY SYNDROME

ST SEGMENT ELEVATION MYOCARDIAL INFARCTION

DEFINITION
- Acute coronary syndrome (ACS) covers a range of

disorders including myocardial infarction (heart

attack) and unstable angina that are caused by the same underlying problem.

- The underlying problem is a sudden reduction of

blood flow to part of the heart muscle. This is usually

caused by a blood clot that forms on a patch of atheroma within a coronary artery (which is

described below).

PATHOPHYSIOLOGY

DIAGNOSIS OF ACS
Ischemic symptoms
Prolonged pain (usually >20 mins) constricting, crushing, squeezing Usually retrosternal location, radiating to left chest, left arm; can be epigastric Dyspnea Diaphoresis Palpitations Nausea/vomiting Light headedness Sense of impending doom

Diagnostic ECG changes

Serum cardiac marker elevations

Troponin T CK-MB CK Myoglob in

LOCATION OF CHEST PAIN DURING HEART ATTACK

SERUM CARDIAC BIOMARKERS

RISK FACTOR FOR ACS

PROGNOSIS BASED ON KILLIP CLASSIFICATION

INITIAL TREATMENT
Fixing the chest pain and fearness
Bed rest Diet O2 2-4 lpm via nasal prongs or face mask Sublingual/oral/IV nitroglycerine Antiplatelet: aspirin and clopidogrel Morfin/petidine Diazepam 2-5mg/8 hour

Stabilizing the hemodynamic (blood pressure and peripheral pulse control)

-blocker if there is no contraindication Calcium channel blocker (CCB) ACE-Inhibitor

Reperfusion of the myocard

Thrombolytic

COMPLICATIONS
Arrythmia Heart failure Cardiogenic shock

Rupture of ventricle septum/wall

Rupture of chordae tendineae

Pericarditis

Tromboemboli

SECONDARY PREVENTION

Smoking cessation
Blood pressure control (less than 140/90 mm Hg, or less than 130/80 mm Hg in patients with diabetes or

five days per week)

Weight management (BMI 18.5 to 24.9 kg per m2; waist circumference less than 40 inches in men, less

chronic kidney disease)

Lipid management (LDL-C level substantially less than 100 mg per dL; nonHDL-C level less than 130

than 35 inches in women)

Diabetes management (A1C less than 7 percent) Antiplatelet and anticoagulant therapy Renin-angiotensin-aldosterone system blocker therapy

mg per dL in patients with

triglyceride levels 200 mg per dL or greater) Physical activity (30 minutes at least