Whole Anterior Wall STEMI Onset >12 hours KILLIP I TIMI Score 2/14

Presented by: Anneke Holly Supervisor : Dr. dr. Idar Mappangara, Sp. PD, Sp.JP, FIHA, FINASIM
Department of Cardiology and Vascular Medicine Medical Faculty of Hasanuddin University

Makassar
2013

PATIENT IDENTITY
Medical Record : 624852 Name : Mr. A Gender : Male Age : 64 years old Address : Mandai Date of admission : 27th August 2013

HISTORY TAKING

Chief Complaint: Chest Pain History of Present Illness: The chest pain began since 14 hours ago before he was admitted to Wahidin Sudirohusodo Hospital. The sensation of chest pain suddenly appeared when the patient was subuh pray. The chest pain felt continuously more than 30 minutes duration, and not relieved by rest. The pain is described like dull heavy feeling on the left chest, radiated to his back, shoulder and left hand. The chest pain was accompanied with cold sweat and tightness sensation. The patient felt nausea and not vomiting. The patient feel breathlessness while having chest pain, and it accompanied by palpitation and cold sweat. He never wakes up from his sleep in the night because of breathlessness. He could sleep with

HISTORY TAKING
History

of Past Illness:

History of chest pain before (-) History of smoking ( + ) 1 packs/day two years ago, but now he smokes 2 pieces/day History of hypertension : denied History of drinking alcohol (-) No history of heart disease No family history of heart disease History of diabetes mellitus : denied No history of dyslipidemia No history of asthma No history of epigastric pain

RISK FACTOR

Non Modifiable
Gender: Male Age : 64 years old

Modifiable

Smoking (+)

PHYSICAL EXAMINATION
General Status Moderate Illness/ Well-nourished /Compos Mentis

Vital Signs BP : 110/70 mmHg HR : 75 bpm, regular RR : 22 tpm T : 36.7C BW : 65 kg H :170 cm

PHYSICAL EXAMINATION

Head Examination
Eyes : Anemic -/-, Icterus -/ Lips : Cyanosis (-) Neck : Lymphadenopathy (-), JVP R+1 cmH2O

Thorax Examination
Insp. Palp. Perc. Ausc. : Symmetrical R=L, normochest : Mass (-), tenderness (-), VF R=L : Sonor : Vesicular Ronchi -/-, Wheezing -/-

PHYSICAL EXAMINATION
Cardiac Examination Insp. : IC wasnt visible Palp. : IC wasnt palpable Perc. : Dull, normal heart size
Right border : Right parasternalis line Left border : Left medioclavicularis line

Ausc. : Pure regular of I/II heart sound, murmur (-)

PHYSICAL EXAMINATION

Abdominal Examination Insp. : Flat and following breath movement Ausc. : Peristaltic sound (+), normal Palp. : Liver and spleen is unpalpable Perc. : Tympani (+), ascites (-)

Extremities Oedema /-

: Pretibial -/-, Dorsum pedis -

ELECTROCARDIOGRAPH Y

Wide QRS

Slurred S

ELECTROCARDIOGRAPHY

ELECTROCARDIOGRAPHY

Interpretation: Rhythm : Sinus Heart Rate : 75 bpm, Regularity : Regular P-Wave Configuration : Normal configuration Duration : 0.08 sec PR-Interval : 0.16 sec QRS Complex Configuration : Q wave formations on lead V2, V3, V4, and V5 Duration : 0.08 - 0.16 sec (Wide QRS on lead V1) Axis : -160 (RAD) ST-Segment : ST-elevation on lead V2, V3, V4, and V5 Slurred S on lead V6 T-Wave : Normal
Conclusion: Sinus Rhythm, RAD, CRBBB, Whole Anterior wall STEMI.

CHEST X-RAY

Normal pulmonary CTI: Normal

Result: Normal Pulmo

LABORATORY EXAMINATION
Laboratory Test ( 27-8-2013) Result WBC RBC HGB HCT PLT PT APTT INR Natrium Kalium Chloride GDS Ureum Creatinine SGOT SGPT CK CKMB 15.8 4.83 14.8 45.2 321 10.2 control 11.9 27.2 control 26.4 0.80 143 4.3 109 126 25 0.6 310 79 4336 336 Normal Range 4.0-10.0 4.50-6.50 14.0-18.0 40.0-54.0 150-400 10-14 22.0-30.0 136-145 3.5-5.1 97-111 140 10-50 M<1.3 ; F<1.1 <38 <41 M<190 ; F<167 <25 Unit 103/mm3 106/mm3 g/dL % 103/mm3 Seconds Seconds mmol mmol mmol mg/L mg/L mg/L U/L U/L U/L U/L

LABORATORY EXAMINATION
Laboratory Test (29-8-2013) Total Cholesterol 186 HDL LDL Trigliseride Troponin T 45 126 65 >2.0

200
M>55; F>65 <130 200 <0.05

mg/dL
mg/dL mg/dL mg/dL -

DIAGNOSIS
Whole Anterior Wall STEMI onset >12 hours KILLIP I TIMI Score 2/14

INITIAL MANAGEMENT

Bed rest O2 2-4 LPM (via nasal canule) IVFD NaCl 0,9% loading 500 cc/24 hours ISDN

Cedocard 0,5 mg/hour/SP 2,5 cc/hour/sp

Anti Platelet Aggregation ASA (Aspilet) loading dose 160 mg single dose; Maintenance 1-0-0 (80 mg) Clopidogrel (Plavix) loading dose 300 mg single dose; Maintenance 01-0 ( 75 mg)

Anti cholesterol HMG-Co A reductase inhibitor (Simvastatine 1 x 20 mg) Anxiolytic Benzodiazepine (Alprazolam 1 x 0,5 mg) Laxative Laxadine syrup 1 x 2 cth

PLANNING
Monitoring Electrocardiography Echocardiography Coronary angiography

ACUTE CORONARY SYNDROME

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

MYOCARDIAL INFARCTION

DEFINITION
Myocardial

infarction (MI) is rapid development of myocardial necrosis caused by imbalance oxygen supply and demand of the myocardium.

It results from plaque rupture with thrombus

formation in a coronary vessels, resulting in an acute reduction of blood supply to a part of the myocardium.

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 STsegment 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 Heart disease diagnosed before age 65 in mother or sister

Modifiable
Smoking Hypertension Diabetes Mellitus Dyslipidemia Obesity Lack of physical activity

WHO DIAGNOSTIC CRITERIA

Clinical history of ischaemic type chest pain lasting >20 minutes

Changes in serial ECG tracings

Rise of serum cardiac biomarkers such as creatinine kinase-MB fraction and troponin

1. ISCHEMIC SYMPTOMS
Prolonged pain (usually >20 minutes) constricting, crushing, squeezing

Usually retrosternal location,

radiating to left chest, left arm; can be epigastric Dyspnea Diaphoresis Palpitations Nausea/vomiting

2. DIAGNOSTIC ECG CHANGES

ECG CHANGES
Timing of myocardial infarction based on ECG

CARDIAC BIOMARKER

CLINICAL HISTORY
Duration : variable, often more than 30 minutes. Quality : Feels squeezing, pressurelike, tightness, heaviness, and burning. Location : Retrosternal, often with radiation to or isolated discomfort in neck, jaw, shoulders, or armsfrequently on left. Associated features : Not relieve with rest or nitrat

DIAGNOSIS
Signs of myocardial ischemia ECG

Yes
ST segmen elevation ?

STEMI
Acute Myocardial Infarction ( Q-wave, non-Q wave )

No

Lab

Yes

Biochemical cardiac markers ?

NSTEMI (No ST-Segment Elevation Myocardial Infarction)

No

Unstable Angina

DIAGNOSIS

Prognosis KILLIP classification

Clas s I II III Description 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 Mortality Rate (%) 6 17 30 - 40

IV

60 80

PROGNOSIS TIMI SCORE

Historical Age 65-74 >/= 75 DM/HTN or Angina 2 points 3 points 1 point 3 points 2 points 2 points

Total Score 0 1 2 3 4 5 6 7 8 9-14

Risk of Death in 30 days 0.8% 1.6% 2.2% 4.4% 7.3% 12.4% 16.1% 23.4% 26.8% 35.9%

Exam
SBP < 100 HR > 100 Killip II-IV

Weight > 67 kg
Presentation Anterior STE or LBBB Time to treatment > 4 hrs Risk Score = Total

1 point
1 point 1 point (0-14)

THANK YOU