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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.

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

)  History of hypertension (-)  History of diabetes melitus (-)  History of dyslipidemia (-) .ANAMNESIS Previous Illness History  History of heart disease ( .

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 .

Wheezing -/- . Icterus (–).PHYSICAL EXAMINATION • General appearance : Moderate illness/well nourished/ composmentis • Vital Signs: BP : 110/70 mmHg HR : 84x/min • RR : 22 x/min T : 36. Palpebra Edema (-) • Neck : JVP R+0 cmH20 • Lung : Vesikuler Rhonchi -/.6°C BW : 97kg H : 173cm Head : Anemia (-) .

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

mass (-) : tympani. ascites (-) • Extremities : Edema -/- . normal : liver and spleen unpalpable.PHYSICAL EXAMINATION • Abdomen : Inspection Auscultation Palpation Percussion : symmetrical big and following breath movement : peristaltic sound (+) .

59. aorta dilatation with aorta dilatation.CHEST X-RAY (9th July 2013) • Cor : expand with CTI: 0. waist of heart concaved. apex lifted (RVE). • Result : Cardiomegaly a b c .

ECG FINDINGS .

36s • QRS Complex : 0.ECG INTERPRETATION • Rhythm • Frequency : AV Block : 45 x/ minute • Axis • P Wave • PR Interval : Normoaxis : 0. aVF : T wave inverted in leads III : Inferior Acute Myocardial Infarction.08s : 0. III.06s • ST Segment • T Wave : ST Segments Elevation in leads II. AV Block 1st degree Conclusion .

7mm .EF 33.IVSd 17.EChocardiography  LV systolic function decreased --.90%  LVH (+) --.

6s : 6.5 mg / dl Cholesterol total : 188 mg/dl HDL : 32 mg / dl LDL : 138 mg / dl Triglyceride : 159mg / dl  APTT : 24.34    Coagulation Time  PT : 11.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 : 1.7 gr/dl : 34.6 mg/dl : 37 u/dl : 14 u/ dl : 120 mg / dl : 4.5s .92 x 106/uL : 11.8% : 261 x 103/µl Enzymes  CK : 603 U/L  Uric acid   Trop T : 0.

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 .

• 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 .DEFINITION • Acute coronary syndromes (ACS) is the clinical manifestation of the critical phase of coronary artery disease.

PATHOPHYSIOLOGY 1 2 3 4 American Heart Association: http://watchlearnlive.org 5 6 .heart.

PATHOPHYSIOLOGY .

May 2009: 109 (5):43 . Overbaugh KJ. older than age 45 • Women. Acute Coronary Syndrome. 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. AJN.Risk factors Non-Modifiable Gender and age. • Men.

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

clopidogrel. et al. tachypnea. • chest pain with/without radiation to arm. hemodynamic instability. tachycardia. and glycoprotein Iib/IIIa inhibitors Anderson JL. lightheadedness. SaO2↓ and rhythm abnormalities •Occurs at rest or with exertion. •O2 to maintain SaO2 level >90% •Nitroglycerin or morphine to control pain •β-blockers. hypotension/ hypertension. LMWH. 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 •β-blockers. limits activity NSTEMI Thrombus partially or intermittently occludes the coronary a. 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. diaphoresis. lightheadedness. and glycoprotein Iib/IIIa inhibitors •Cardiac catheterization and possible PCI for patients with ongoing chest pain. tachycardia. nausea.. SaO2↓ and rhythm abnormalities •Occurs at rest or with exertion. SaO2↓ and rhythm abnormalities •Occurs at rest or with exertion. 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 •β-blockers. statins. tachypnea. Hazinski MF. or increased risk of worsening clinical condition .116(7):e148-e304. back or epigastric region •Shortness of breath. hypotension/ hypertension. angiotensinconverting enzyme inhibitors. diaphoresis. back or epigastric region •Shortness of breath. hypotension/ hypertension. diaphoresis.Differences Unstable Angina Thrombus partially or intermittently occludes the coronary a. neck. statins. neck. et al. nausea. lightheadedness. back or epigastric region •Shortness of breath. • chest pain with/without radiation to arm. Circulation 2007. tachycardia. angiotensinconverting enzyme inhibitors. Handbook of emergency cardiovascular care for healthcare providers. LMWH. tachypnea. clopidogrel. c`lopidogrel. nausea. editors. statins. Dallas:American Heart Association. neck. 2008. angiotensinconverting enzyme inhibitors.

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2011 (59):20. Supplement to JAPI.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. Approach to STEMI and NSTEMI.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. .

Management .

Oxygen (2-4L/mnt) 4. Bed Rest 2. . Diet 3. 2013 ACC/AHA Guideline STEMI .Aspirin 162-325mg chewed immediately and 81-162 mg continued indefinitely. Anti platelet therapy : .4 mg SL tablets every 3-5 min up to 3 times. Nitroglycerin 0.Initial Treatment 1. 5.Clopidogrel 300-600mg loading dose and 75mg daily continued for at least 14 days and up to 12 months. can continue with an IV drip of 50mg in 250mL Dextrose 5%. if effect is not sustained.

9. Fibrinolytic therapy: a) Streptokinase 1. Anticoagulation therapy: a) Low Molecular Weight Heparins ( Fondaparinux) 2. Morphine 2-5mg iv Q5-30min 7. Statins Simvastatin 20mg qd .5mg/24hrs/sc for up to 8 days post-MI.Initial Treatment 6.5mg/kg body weight iv 8.5million units iv b) Tenecteplase 0.

within 90 ‘min. min. Published ahead of print on December . InterHospital Transfer 5 8 EMS Transport min. GOALS PCI capable Antman EM. • Consider prehospital fibrinolytic if capable and EMS-to-needle within 30 min. ACC/AHA STEMI Guideline 2009 . Golden Hour = first 60 min. fibrinolysis Patient self-transport EMS-to-needle Hospital door-to-balloon within 30 min. Total ischemic time: within 120 min. J Am Coll Cardiol 2008. et al.Options for Transport of Patients With STEMI and Initial Reperfusion Treatment Hospital fibrinolysis: Door-to-Needle within 30 min. EMS transport Patient EMS Prehospital EMS-to-balloon within 90 min. Not PCI capable Onset of symptoms of STEMI 9-1-1 EMS Dispatch EMS on-scene • Encourage 12-lead ECGs.

40 60 – 80 . and evidence of peripheral vasoconstriction 17 III IV 30 .PROGNOSIS KILLIP CLASSIFICATION Class I Description No clinical signs of heart failure Mortality Rate (%) 6 II Rales or crackles in the lungs. and elevated jugular venous pressure Acute pulmonary edema Cardiogenic shock or hypotension (systolic BP < 90 mmHg). an S3.

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