STEMI INFERIOR ONSET > 24 HOURS KILLIP 1

Presented by: Viesna Beby Auliana Pembimbing : dr. Abubakar S Zubeidi

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

IDENTITAS PASIEN
Medical Nama Jenis Usia Alamat Tanggal

Record

kelamin

2013

Masuk

: 624749 : Ms.MR : Female : 58 years old : Jl.Rappokalling : September 9th

ANAMNESIS

Keluhan utama: Nyeri dada

Anamnesis terpimpin: TheNyeri dada dirasakan sejak 1 hari sebelum masuk rumah sakit (13.00, 1 September). Nyeri dirasakanseperti tertindih benda berat pada dada dan menjalar ke lengan kiri tembus ke belakang. Terdapat riwayat nyeri dada 3 bulan yang lalu tetapi membaik dengan beristirahat. Nyeri dada disertai dengan keringat dingin. Mual (-), muntah (-), sesak (-), BAB dan BAK normal

RIWAYAT

Riwayat Penyakit Sebelumnya:

Riwayat nyeri dada 3 bulan yang lalu namun membaik dengan beristirahat

Riwayat HT (+) 10 tahuin yang lalu tidak berobat teratur

Tidak ada riwayat penyakit jantung sebelumnya. Riwayat keluarga dengan penyakit yang sama tidak ada. Riwayat DM (+) sejak tahun 2007 tidak berobat teratur

Tidak ada riwayat dislipidemia

Tidak ada riwayat asma

FAKTOR RESIKO
Non Modifiable Usia : 58 tahun
Modifiable

Hipertensi(+)

DM (+)

PEMERIKSAAN FISIK

Keadaan umum Sakit sedang/gizi cukup/sadar Tanda Vital

BP HR RR T BW H

: 120/80 mmHg : 72 bpm, regular : 20 tpm : 36.7C : 55 kg : 159 cm

PEMERIKSAAN FISIK

Pemeriksaa kepala

Mata Bibir Leher

: Anemic -/-, Icterus -/: Cyanosis (-) : Lymphadenopathy (-), JVP R+1 cmH2O

Pemeriksaan Dada

Insp. Palp. Perc. Ausc.

: Symmetrical R=L, normochest : Mass (-), NT(-), VF R=L : Sonor : Bronchovesicular Ronchi -/-, Wheezing -/-

PEMERIKSAAN FISIK
Pemeriksaan
Insp. Palp.

Jantung

Perc.

: IC tidak terlihat : IC tidak teraba : Dull

: garis parastrenalis kanan : 2 jari setelah linea midclavicularis kiri

Batas kanan Batas kiri

Ausc.

: BJ I/II murni reguler, gallop (-)

PEMERIKSAAN FISIK
Pemeriksaan

abdomen

Insp. Ausc. Palp. Perc.

: Datar, ikut gerak napas : peristaltik(+), normal : Liver and spleen tidak teraba : Tympani (+), ascites (-)

Ekstremitas

Oedema /-

: Pretibial -/-, Dorsum pedis -

ELECTROCARDIOGRAPHY ECG

Interpretation
Sinus Rhythm Heart Rate :75x/I P Wave : 0.08 PR interval :0.16 ST elevasi III &

AVF T inverted di II, III, dan AVF V3V5 Axis : normoaxis

LABORATORY EXAMINATION
WBC

: 9,50 HB : 16,7 gr/dl PLT : 288.000 HCT : 45,6 % GDS : 358mg/dl Ureum : 17mg/dl Creatinin : 0,5 mg/d

CK CKMB Trop. T Na K Cl SGOT SGPT Albumin

: 640 U/L : 79U/L : 0,59 : 134mmol/l : 3,8mmol/ : 103mmol/l : 94U/L : 20U/L : 41

DIAGNOSIS
-

STEMI inferior, onset <24 hours KILLIP I DM Tipe 2

INITIAL MANAGEMENT

Bed rest O2 2-4 LPM (via nasal canule) Heart Diet IVFD NaCl 0,9% loading 500 cc/24 hours 140/90 mmHg Anti Platelet Aggregation ASA (Aspilet) loading dose 160 mg (2 x 80 mg) maintenance 1-0-0 Clopidogrel (Plavix) loading dose 300 mg (4 x 75 mg) maintenance 0-1-0 Anti cholesterol HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg) Anti coagulant Low Molecule Weight Heparin(Fondaparinux(Arixtra)) 2,5 mg/24 jam/SC Anxiolytic Benzodiazepin (Alprazolam 1 x 0,5 mg) Laxative Laxadin syrup 1 x 2 cth

PLANNING
Echocardiography Coronary

angiography

ACUTE CORONARY SYNDROME

DIAGNOSIS OF CHEST PAIN

1 point
Retrosternal or substernal chest pain

1 point

Increased by activity or emotion

1 point

Relieved by resting or nitrate SL

3 point typical chest pain 2 point atypical chest pain 1 point or none non cardiac chest pain

Tend to be Stable Angina Pectoris than Acute Coronary Syndrome

Tend to be Acute Coronary Syndrome than Non Cardiac Chest Pain

DEFINITION
Acute Coronary Syndrome (ACS) is a term for situations where the blood supplied to the

heart muscle is suddenly blocked.

describe a group of conditions resulting from acute myocardial ischemia (insufficient blood flow to heart muscle) ranging from unstable angina (increasing, unpredictable chest pain) to myocardial infarction (heart attack).

CLASSIFICATION

PATHOPHYSIOLOGY

Vulnerable Plaque Thrombosis Vasospasme Plaque disruption and thrombosis that result in complete coronary artery occlusion leads to transmural ischemia and necrosis, the hallmark of ST-segment elevation myocardial infarction (STEMI)

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

Modifiable
Smoking Hypertension Diabetes Mellitus Dyslipidemia Obesity

Heart disease diagnosed before

age 65 in mother or sister

Lack of physical activity

At least 2 of the following:

1. Ischemic symptoms 2. Diagnostic ECG changes 3. Serum cardiac marker elevations

DIAGNOSIS OF ACS

CLINICAL FEATURES
Substernal chest pain / chest discomfort radiated to the left arm, shoulder, neck, jaw. Penetrated to the back. The chest discomfort may also be described as a dull pain ,pressure, squeezing or crushing sensation or burning sensation Duration more than 20 minutes. more intense and persistent.

Not fully relieved by rest or nitroglycerine

Often accompanied by systemic symptoms: nausea, vomiting, SOB, palpitation, fatigue, cold sweat, light headness

2. DIAGNOSTIC ECG CHANGES

3. SERUM CARDIAC MARKER ELEVATIONS

Troponin T CK-MB CK

SGOT

LDH

Myoglobin

DIAGNOSIS

INITIAL MANAGEMENT

Fixing the chest pain and fearness Bed rest Diet O2 2-4 lpm Nitroglycerin: 0,4 mg SL tablets every 3-5 minutes up to 3 times; if effect is not sustained, can continue with an IV drip of 50 mg in 250 ml dextrose 5% Antiplatelet : Aspirin: 162-325 mg chewed immediately and 81-162 mg continued indefinetely Clopidogrel 300-600 mg loading dose and 75 mg daily continued for at least 14 days and up to 12 months. Morphine 2-5 mg IV every 5-30 minutes Pethidine 12,5 mg/IV Diazepam 2-5mg/8 hour Stabilizing the hemodynamic (blood pressure and pheripheral pulse control) -blocker Calcium channel blocker (CCB) ACE-Inhibitor Reperfusion of the myocard Thrombolytic: streptokinase 1,5 million units/IV

PROGNOSIS KILLIP CLASSIFICATION

Class Description Mortality Rate (%)

I
II III

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

6
17 30 - 40

IV

60 80

THANK YOU