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April 2015
Patients Identity
Name
: Mr. B
Gender
: Male
Age
: 46 years old
Registration no.
: 708726
: CVCU
History Taking
Chief Complaint:
Chest pain
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
Neck
Thorax :
Inspection
Palpation
: Symmetrical left=right
Percussion
Auscultation
-/-
: Sonor
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
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
Troponin T
>2,0
<0,05
RBC
5,09 x 106/uL
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
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.
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.
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 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:
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
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
COMPLICATIONS
Arhythmia
Congestive Heart Failure
Cardiogenic shock
Thromboembolism
VSD
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
17
30 - 40
60 80
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