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STEMI INFERIOR ONSET > 24 HOURS

KILLIP 1

Presented by:Viesna Beby Auliana

Pembimbing :

dr. Abubakar S Zubeidi

Department of Cardiology and Vascular MedicineMedical Faculty of Hasanuddin University

Makassar

2013


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IDENTITAS PASIEN

Medical Record : 624749

Nama : Ms.MR

Jenis kelamin : Female

Usia : 58 years old

Alamat : Jl.Rappokalling

Tanggal Masuk : September 9th

2013


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ANAMNESIS Keluhan utama:

Nyeri dada

Anamnesis terpimpin:

TheNyeri dada dirasakan sejak 1 hari sebelum masuk rumah sakit (13.00, 1September). 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


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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


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FAKTOR RESIKO

Usia : 58

tahun

NonModifiable

Hipertensi(+)DM (+)

Modifiable


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PEMERIKSAAN FISIK Keadaan umum

Sakit sedang/gizi cukup/sadar

Tanda Vital BP : 120/80 mmHg HR : 72 bpm, regular RR : 20 tpm

T : 36.7C BW : 55 kg H : 159 cm


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PEMERIKSAAN FISIK Pemeriksaa kepala

Mata : Anemic -/-, Icterus -/- Bibir : Cyanosis (-)

Leher : Lymphadenopathy (-), JVP R+1 cmH2O

Pemeriksaan Dada Insp. : Symmetrical R=L, normochest Palp. : Mass (-), NT(-), VF R=L Perc. : Sonor

Ausc. : BronchovesicularRonchi -/-,Wheezing -/-


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PEMERIKSAAN FISIK

Pemeriksaan Jantung

Insp. : IC tidak terlihat

Palp. : IC tidak teraba

Perc. : Dull

Batas kanan : garis parastrenalis kanan

Batas kiri : 2 jari setelah linea midclavicularis kiri

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


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PEMERIKSAAN FISIK

Pemeriksaan abdomen

Insp. : Datar, ikut gerak napas

Ausc. : peristaltik(+), normal Palp. : Liver and spleen tidak teraba

Perc. : Tympani (+), ascites (-)

Ekstremitas Oedema : Pretibial -/-, Dorsum pedis -

/-


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ELECTROCARDIOGRAPHYECGInterpretationSinus Rhythm

Heart Rate :75x/I

P Wave : 0.08

PR interval :0.16

ST elevasi III &AVF

T inverted di II,III, dan AVF V3-V5

Axis :normoaxis


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LABORATORY EXAMINATION

WBC : 9,50

HB : 16,7 gr/dl

PLT : 288.000

HCT : 45,6 %

GDS : 358mg/dl

Ureum : 17mg/dlCreatinin : 0,5 mg/d

CK : 640 U/L

CKMB : 79U/L

Trop. T : 0,59 Na : 134mmol/l

K : 3,8mmol/

Cl : 103mmol/l

SGOT : 94U/L SGPT : 20U/L

Albumin : 41


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DIAGNOSIS

- STEMI inferior, onset


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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


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PLANNING

Echocardiography

Coronary angiography


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ACUTE CORONARYSYNDROME


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DIAGNOSIS OF CHEST PAIN

3 point typical chest pain

Tend to be Stable Angina Pectoris than AcuteCoronary Syndrome

2 point atypical chest painTend to be Acute Coronary Syndrome than NonCardiac Chest Pain

1 point or none non cardiac chestpain

Retrosternalor substernalchest pain

1point Increased

by activityor emotion

1point Relieved by

resting ornitrate SL

1point


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DEFINITIONAcute 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).


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CLASSIFICATION


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PATHOPHYSIOLOGY Vulnerable Plaque

Thrombosis

Vasospasme

Plaque disruption andthrombosis that result incomplete coronaryartery occlusion leadsto transmural ischemia

and necrosis, thehallmark of ST-segmentelevation myocardialinfarction (STEMI)


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Lipid transport disorder Inflamation

Plaque deposition

Stable plaque Plaque ruptureErosion

Stable angina pectorisThrombosis

Thrombus

Acute coronary syndrome:

Unstable angina

Myocardial infarction :

- Non Q waves

- Q waves

PATHOGENESIS


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RISK FACTOR

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

Non- Modifiable Modifiable

Smoking

Hypertension

Diabetes Mellitus

Dyslipidemia

Obesity

Lack of physical activity


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At least 2 of the following:DIAGNOSIS OF ACS

1. Ischemic symptoms

2. Diagnostic ECG changes

3. Serum cardiac marker elevations


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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


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2. DIAGNOSTIC ECG

CHANGES


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3. SERUM CARDIAC MARKER

ELEVATIONS

TroponinT CK-MB CK

SGOT LDH Myoglobin


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DIAGNOSIS


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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 notsustained, 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 continuedindefinetely

Clopidogrel 300-600 mg loading dose and 75 mg daily continued for at least14 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


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PROGNOSIS

KILLIP CLASSIFICATIONClass Description Mortality Rate (%)

I No clinical signs of heart failure 6

IIRales or crackles in the lungs, an S3,and elevated jugular venouspressure

17

III Acute pulmonary edema 30 - 40

IV

Cardiogenic shock or hypotension(systolic BP < 90 mmHg), andevidence of peripheralvasoconstriction

6080


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