ST-ELEVATION MYOCARDIAL INFARCTION

DEFINISI

Infark miokard akut adalah nekrosis miokard yang disebabkan oleh tidak adekuatnya pasokan darah akibat sumbatan akut arteri koroner. IMA dengen elevasi segmen ST merupakan bagian dari spektrum Sindroma koroner akut.

Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals
 Cigarette smoking  Hypertension (BP 140/90 mmHg or on

antihypertensive medication)  Low HDL cholesterol (<40 mg/dL)†  Family history of premature CHD  CHD in male first degree relative <55 years  CHD in female first degree relative <65 years  Age (men 45 years; women 55 years)

HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.

Life-Habit Risk Factors
 Obesity (BMI  30)  Physical inactivity  Atherogenic diet

Emerging Risk Factors
 Lipoprotein (a)  Homocysteine  Prothrombotic factors

 Proinflammatory factors
 Impaired fasting glucose  Subclinical atherosclerosis

PATOFISIOLOGI STEMI

Atherosclerosis Timeline
Foam Cells Fatty Streak Intermediate Atheroma Lesion Fibrous Complicated Plaque Lesion/Rupture

Endothelial dysfunction
From first decade From third decade From fourth decade
Smooth muscle and collagen Thrombosis, haematoma

Growth mainly by lipid accumulation

Adapted from Stary HC et al. Circulation 1995;92:1355-1374.

Dislipidemia ----- Atherosclerosis ---- CVD A Progressive Disease
Plaque rupture Monocyte LDL-C Adhesion molecule Macrophage Oxidized LDL-C Foam cell CRP

Smooth muscle cells

Endothelial dysfunction

Inflammation

Oxidation

Plaque instability and thrombus

CRP=C-reactive protein; LDL-C=low-density lipoprotein cholesterol. Libby P. Circulation. 2001;104:365-372; Ross R. N Engl J Med. 1999;340:115-126.

Atherothrombosis: Thrombus Superimposed on Atherosclerotic Plaque

Adapted from Falk E, et al. Circulation. 1995;92:657-671.

Myocardial Hypoxia
↓ ATP

Impaired Na+, K+ - ATPase
↑ Extracellular K+

↑ Anaerobic metabolism ↑ Intracellular H+ Chromatin clumping Protein denaturation

↑ Intracellular Na+

↑ Intracellular Ca++

Altered membrane potential

Intracellular edema
↓ ATP ↑ Proteases ↑ Lipases

Arrhytmias

Adapted from Naik H, Sabatine MS, Lilly LS, 2007. Acute Coronary Syndrome. In: Lilly LS, ed. Pathophysiology of Heart Disease 4th Edition. USA: Lippincott Williams & Wilkins; 168-196

CELL DEATH

Pathology & ECG

Diagnosis of Acute MI STEMI / NSTEMI
 At least 2 of the

following
 Ischemic symptoms  Diagnostic ECG changes  Serum cardiac marker elevations

Time is muscle

Pemeriksaan Penunjang
1. EKG
2. Enzim jantung

ECG assessment
ST Elevation or new LBBB STEMI
ST Depression or dynamic T wave inversions

NSTEMI
Non-specific ECG

Unstable Angina

Diagnosis Banding
1. perikarditis akut
2. Emboli paru 3. Diseksi aorta akut 4. Kostokondritis 5. Gangguan gastrointestinal

Acute Management
 Initial evaluation & stabilization  Efficient risk stratification  Focused cardiac care

Chest pain suggestive of ischemia
Immediate assessment within 10 Minutes
Initial labs and tests
 12 lead ECG  Obtain initial

Emergent care
IV access  Cardiac monitoring  Oxygen  Aspirin  Nitrates

History & Physical
Establish diagnosis  Read ECG  Identify complication s  Assess for reperfusion

cardiac enzymes  electrolytes, cbc lipids, bun/cr, glucose, coags  CXR

Focused History
 Aid in diagnosis and

rule out other causes
 Palliative/Provocative     

 Reperfusion

questions
 Timing of

factors Quality of discomfort Radiation Symptoms associated with discomfort Cardiac risk factors Past medical history especially cardiac

presentation  ECG c/w STEMI  Contraindication to fibrinolysis  Degree of STEMI risk

Terapi
       

Aspirin 150-300 mg Clopidogrel 300 mg Oksigen 2-4 L Nitrat sublingual Morfin 2-5 mg intravena Penilaian dan stabilisasi hemodinamik Monitoring EKG Nilai kemunkinan reperfusi (fibrinolitik atau PCI Primer)

Komplikasi
 Aritmia
 Syok kardiogenik  Edema paru akut  Perikarditis

Prognosis
 Killip
 TIMI Risk

STATUS PASIEN

DATA PRIBADI
 Nama pasien
      

: Tn. N. Pasaribu Umur : 49 Tahun Jenis kelamin : Laki-Laki Pekerjaan : Wiraswata Alamat : Desa Simorangkir Agama : Kristen Tanggal Masuk : 15 April 2011 Berat badan : 95 kg ; Tinggi badan : 176 cm

ANAMNESA
 KeluhanUtama  Anamnese

: Nyeri dada : hal ini dialami pasien sejak 2 hari sebelum masuk rumah sakit. Nyeri seperti terbakar di dada kiri dan menjalar ke rahang bawah. Awalnya nyeri dirasakan setelah pasien berkebun. Nyeri tersebut tidak berkurang dengan beristirahat. Keringat dingin tidak dijumpai. Pasien mengeluh mual selama serangan, mual (-). Setelah 4 jam os merasakan nyeri yang terus-menerus, os berobat ke praktek dokter umum di Tarutung, dan os dinyatakan menderita sakit jantung. Os diberikan ISDN oleh dokter di Tarutung tersebut dan kemudian os dirujuk ke RS di Medan. Nyeri dirasakan sedikit berkurang setelah diberi ISDN. Kemudian os berobat ke praktek dr. P. ManikSp.JP(K) dan oleh dokter tersebut os dirujuk ke RS HAM. Saat tiba di UGD RS HAM, pasien masih mengeluhkan nyeri di dada kirinya. Riwayat sesak nafas, jantung berdebar, kaki bengkak, pingsan, dan batuk tidak ditemui.

Riwayat merokok dijumpai sejak kira-kira 25 tahun lalu, setengah bungkus per hari. Os sudah 8 tahun terakhir berhenti merokok. Konsumsi alkohol dan tuak dijumpai. Os menderita sakit asam urat selama 5 tahun ini  Faktor resiko PJK : laki-laki, obesitas, exsmoker, DM (-), hipertensi (-), riwayat PJK dalam keluarga (-)  Riwayat Penyakit Terdahulu : asam urat  Riwayat Pemakaian Obat : Tidak jelas

PEMERIKSAAN FISIK
KeadaanUmum : lemah Status present :C M TD : 100/60 mmHg HR : 85 x/i RR : 24x/i Temp : 36,5ºC Anemia (-) Sianosis (-) Ikterus (-) Dyspnoe (-) Edema (-) Ortopnoe )

(-

 Kepala: mata :konjungtivapalpebra inferior

pucat (-/-), sclera ikterik (-/-), RC (+/+) pupil isokor ka=ki  Leher : JVP R+2 cmH2O  Thorax :
 Inspeksi

: Simetrisfusiformis  Palpasi: SF ka = ki, kesannormal  Perkusi : sonordikedualapanganparu  Auskultasi : vesikuler

 Jantung:

Batas atas :ICS III sinistra Batas kanan:Linea sternalisdextra ICS V Batas kiri :1cm medial LMCS ICS V
S1 (N), S2 (N), S3 (-), S4 (-) Regulitas: reguler Murmur - Punctum maximum : -Radiasi: -

 Paru:

SP : vesikuler ST :Rongkibasah(-)
(-)  Abdomen:
 Palpasi: soepel  H/L/R : tidakterabapembesaran  Asites: (-)

wheezing

 Ekstremitas
akralhangat

:

 Superior : sianosis (-), clubbing finger (-)  Inferior : oedemapretibial (-), pulsasiarteri (+/+),

 Interpretasi EKG

EKG TARUTUNG  SR, QRS rate 79x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III, AVF; Q path. : - , T inverted -, LVH -, RVH -, VES –  Kesan : SR + STEMI inferior

 INTERPRETASI EKG

EKG RS HAM (CVCU)  SR, QRS rate 64x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III, AVF; Q path. : III, AVF T inverted II, III, AVF; LVH -, RVH  Kesan : SR + STEMI inferior

 INTERPRETASI FOTO THORAX  CTR: 50%, Segemen

Aorta danpulmonal : Normal, , PinggangJantung : (-), Apex downward, Kongesti (+), Infiltrat ().  KESAN : normal

HASIL LABORATORIUM
DarahLengkap :  Hb
  

: 17 g % : 5, 92 x 106/mm3

FaalHati  SGOT

: 130 U/L : 46 U/L

Eritrosit

SGPT

Leukosit : 14,4 x 103/mm3 Hematokrit : 52,9 %

Troponin– T : 1,8 CK-NAC CK-MB :805 :77

Trombosit

: 223 x 103/mm3

AGDA :
  

pH pCO2 pO2

: 7,425 : 32,1 mmHg : 108,9 mmHg

Glukosadarahsewaktu : 142 mg/dL Ginjal
 


  

HCO3 Total CO2 BE
SaO2

: 21,3 mmol/L : 21,5 mmol/L : -2,6 mmol/L
: 98,2%

Ureum : 36 mg/dL Kreatinin

: 0,72 mg/dL

Elektrolitserum
  

Natrium (Na) Kalium (K) Klorida (Cl)

: 127 mEq/L : 4,8 mEq/L : 111 mEq/L

 DIAGNOSA

Diagnosis kerja: STEMI inferior onset 2 harikillip I TIMI risk 2/14  Fungsional : KILLIP I  Anatomi: Right Coronary Artery  Etiologi:arterosklerosis

        

PENGOBATAN Bedrestsemifowler O2 2-4 L/I Inj.enoxaparin0,6 cc/12 jam (5 hari) Clopidogrel 4x75mg, selanjutnya 1x 75 mg Aspilet2x80mg, selanjutya 1x 80 mg ISDN 3x5mg Simvastatin 1x40mg Captopril3x6,25mg Morfin 2,5 mg IV

 RENCANA PEMERIKSAAN

SELANJUTNYA  Lipid profile  Angiografikoroner

 PROGNOSIS  Vitam

ad bonam  Functionam : dubia ad bonam  Sanactionam : dubia ad bonam

: dubia

FOLLOW UP EKG  13 April 2011 (RS TARUTUNG) SR, QRS rate 79x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III, AVF; Q path. : - , T inverted -, LVH -, RVH -, VES – Kesan: SR + STEMI inferior  15 April 2011 (IGD RS HAM, Pukul 18.11) SR, QRS rate 69x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III, AVF; Q path. : III, AVF , T inverted II, III, AVF ;LVH -, RVH -, VES – Kesan: SR + STEMI inferior  15 April 2011 (CVCU, Pukul 19.00) SR, QRS rate 64x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III, AVF; Q path. : III, AVF T inverted II, III, AVF; LVH -, RVH -,VESKesan: SR + STEMI inferior

 16 April 2011 (Ruangan, Pukul 05.15)

SR, QRS rate 63x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III, AVF; Q path. : III, AVF; T inverted II, III, AVF; LVH -, RVH -,VESKesan : SR + STEMI inferior  18 April 2011 (Ruangan, Pukul 07.00) SR, QRS rate 73x, QRS axis : normo axis, P wave (+) normal, PR interval 0.2”, QRS duration 0,08, ST elevasi : (-); Q path. : III , T inverted II, III, AVF; LVH -, RVH -, VES – Kesan : SR + STEMI inferior

TERIMA KASIH