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Case Report

April 2015

STEMI Whole Anterior ONSET >12


HOURS KILLIP II
By:
Kristina Sabari
Supervisor :
Prof. dr. Peter Kabo, PhD, Sp.FK,
Sp.JP(K),FIHA,FAsCC

Medical Faculty of Hasanuddin University,


Makassar 2015

Patients Identity
Name

: Mr. B

Gender

: Male

Age

: 46 years old

Registration no.

: 708726

Date of admission : April 16th2015


Room

: CVCU

History Taking
Chief Complaint:
Chest pain

History of Present Illness:


Left chest pain felt since one day prior to
admission.
Described as compressed pain and radiating to left
arm, intermittently, duration of pain : > 20 minutes
associated with shortness of breath and cold
sweating
dyspnea, nausea and vomiting were present

History of Past Illness


Past Illness History :
History of smoking, 1 packs per day since young
History of chest pain on left chest about 1 year ago
No history of hypertension
No history of Diabetes Mellitus
No history alcohol consumption
No family history of heart disease

Risk Factors
Modified Risk Factor:
-Smoking
-Lack of activity
Non-modified Risk Factor:
-Gender: Male
-Age : 46 years old

PHYSICAL EXAMINATION
General Status
Moderate illness / Normal / Conscious
Weight

: 60 kg

Height : 165 cm
BMI

: 22,00 kg/m2

Vital Status
Blood pressure
Heart rate

: 88 bpm

Respiratory rate
Temperature

:100/70 mmHg
: 20 rpm
: 36,7 oC

Cont
Head

: Anemic (-), icterus (-), cyanosis (-)

Neck

: Lymphadenopathy (-), JVP R+2 cmH2O

Thorax :
Inspection
Palpation

: Symmetrical left=right

Percussion
Auscultation
-/-

: Sonor

: Mass (-), tenderness (-), normal vocal fremitus


: Bronchovesicular, basal ronchi +/+, wheezing

Cont
Heart :
Inspection : ictus cordis not visible
Palpation : ictus cordis not palpable, thrill (-)
Percussion : Dull
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea axillaris anterior sinistra

Auscultation

: heart sound I/II pure, regular, murmur (-)

Cont
Abdomen :
Inspection : flat and follows breath movement
Auscultation
: Peristaltic sound (+), normal
Palpation : Liver and spleen unpalpable
Percussion : Tympani (+), ascites (-)
Extremities :
Edema (-)

LABORATORY FINDINGS
TEST

RESULT

NORMAL VALUE

Glucose

103 mg/dL

<140

SGOT

500 u/L

<38

SGPT

103 u/L

<41

Ureum

70

10-50

TEST

RESULT

NORMAL VALUE

Creatinine

1,1

0,5-1,2

WBC

22,6x 103/uL

4.0 10.0 x 103

Troponin T

>2,0

<0,05

RBC

5,09 x 106/uL

4.0 6.0 x 106

CK

4699,0

<190

HGB

15,0 g/dL

12 18

CKMB

233,3

<25

HCT

45,0%

37 48

Natrium

137

136 - 145

PLT

388 x 103/uL

150 400 x 103

Kalium

4,8

3,5 - 5,1

PT

9,8

10 - 14

Chloride

101

97 - 111

APTT

30,7

22,0 - 30,0

Uric Acid

4,8

3,4-7,0

ELECTROCARDIOGRAPHY

CHEST XRAY

Result :
Cardiomegaly (CTI
index : 0.61)
Pulmonary edema
:
Card

DIAGNOSIS
STEMI whole anterior onset >12 HOURS
KILLIP II

MANAGEMENT

Bed rest
O2 2-4 lpm via nasal cannula
IVFD NaCl 0,9% 500 cc/24 hours/IV
Aspirin 80 mg/24 hours/oral
Clopidogrel 75 mg/24 hours/oral
Captopril 6,25mg/8 hours/oral
Fondaparinux 2,5mg/24 hours/subcutaneous
Isosorbide Dinitrate 1mg/hour/syringe pump
Furosemide 40 mg/12 hours/ IV
Ceftriaxone 2gr/24 hours/IV
Laxadine syr 10cc/24 hours/oral
Alprazolam 0,5 mg/ 24 hours/oral

PLANNING

Echocardiography
Coronary angiography

DISCUSSION

DEFINITION
Myocardial infarction (MI) is a rapid
development of myocardial necrosis caused
by a critical imbalance between the oxygen
supply and demand of the myocardium. This
usually results from plaque rupture with
thrombus formation in a coronary vessels,
resulting in an acute reduction of blood
supply to a portion of the myocardium.

European Heart Journal 2012: ESC Guidelines

PATHOPHYSIOLOGY

Occurs

when
coronary blood flow
decreases
abruptly
after a thrombotic
occlusion
of
a
coronary
artery
previously affected by
atherosclerosis.
In
most cases, infarction
occurs
when
an
atherosclerotic plaque
fissures, ruptures, or
ulcerates.

European Heart Journal 2012: ESC Guidelines

DIAGNOSIS

ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment
elevation. European Heart Journal (2011)

Unstable Angina

NSTEMI

STEMI

Non occlusive
thrombus

Occluding
thrombus
sufficient to cause
tissue damage &
mild
myocardial
necrosis

Complete thrombus
occlusion

Non specific
ECG

ST depression +/T wave inversion


on
ECG

ST elevations on
ECG or new LBBB

Normal cardiac
enzymes

Elevated cardiac
enzymes

Elevated cardiac
enzymes

RISK FACTORS

Diagnosis Of ACS
At least 2 of the followings:

Oxford Handbook of Clinical Medicine 6 th Edition

Diagnosis Of ACS
Ischemic symptoms

Prolonged pain
(usually >20
minutes)
constricting,
crushing, squeezing
Usually retrosternal
location, radiating
to left chest, left
arm; can be
epigastric
Dyspnea
Diaphoresis

Oxford Handbook of Clinical Medicine 6th Edition

Palpitations

Diagnosis Of ACS
Diagnostic ECG changes

Patophysiology of Heart Disease - A Collaborative Project of Medical Students and Faculty Leonard S Lilly, 5th edition

Diagnosis Of ACS
Serum cardiac marker
elevations
Troponin T
CK-MB
CK
Myoglobin

Patophysiology of Heart Disease - A Collaborative Project of Medical Students and Faculty Leonard S Lilly, 5th edition

INFARCT LOCATION

Fauci, Braunwald, dkk. 17thEdition Harrisons Principles of Internal Medicine. New South Wales: McGraw

GOAL OF TREATMENT
Relieve pain
Myocardial perfusion
Hemodynamic stabilization
Prevent the complication

a report of the American College of Cardiology American Heart Association Task Force on Practice Guidelines. 2008;51:210

MANAGEMENT

Bed rest
Oxygen (2-4 lpm)
Anti platelet therapy :
-Aspirin 162-325mg chewed immediately and 81162 mg continued indefinitely.
-Clopidogrel 300-600mg loading dose and 75mg
daily continued for at least 14 days and up to 12
months.
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%.

MANAGEMENT

Morphine 2-5mg iv (can be administered again in


5-30 minutes later)
Fibrinolytic therapy:
-Streptokinase 1.5million units iv
-Tenecteplase 0.5mg/kg body weight iv
Anticoagulation therapy:
-Low Molecular Weight Heparin (Fondaparinux)
2.5mg/24hrs/sc for up to 8 days post-MI.
-Unfractionated heparin : Bolus 60units/kg body
weight (maximum 4000U), infuse 12units/kg body
weight/hour (maximum 1000U/hour)
Anti Hypertensive Drugs
Lipid Lowering Agents

European Heart Journal 2012: ESC Guidelines

COMPLICATIONS
Arhythmia
Congestive Heart Failure
Cardiogenic shock
Thromboembolism
VSD

TIMI RISK SCORE FOR STEMI


Risk Factor
Age > 65 years old
Age > 75 years old

Score
2
3

Risk of
Total
Death in 30
Score
days
0
0.8%
1
1.6%
2
2.2%
3
4.4%
4
7.3%
5
12.4%
6
16.1%
7
23.4%
8
26.8%
9-14
35.9%

History of
angina/hipertension/D 1
M
Systolic BP <100
3
Heart rate > 100
2
Killip II-IV
2
Weight > 67kg
1
Anterior MI or LBBB
1
Delay
treatment
Acute coronary
syndrome, 3rd ed.Revised and expanded

KILLIP CLASSIFICATION

Class
Description
I
no clinical signs of heart failure
II

III
IV

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

Mortality Rate (%)


6

17

30 - 40
60 80

Acute coronary syndrome, 3rd ed.Revised and expanded

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