ST-ELEVATION MYOCARDIAL INFARCTION

Infark miokard akut adalah nekrosis miokard yang disebabkan oleh tidak adekuatnya pasokan darah akibat sumbatan akut arteri koroner.

IMA dengen elevasi segmen ST merupakan bagian dari spektrum Sindroma koroner akut.

Major Risk Factors (Exclusive of LDL Cholesterol) That Modify LDL Goals Cigarette smoking Hypertension (BP 140/90 mmHg or on

antihypertensive medication) Low HDL cholesterol (<40 mg/dL)† Family history of premature CHD

CHD in male first degree relative <55 years CHD in female first degree relative <65

years Age (men 45 years; women 55 years)

† HDL cholesterol 60 mg/dL counts as a “negative” risk factor; its presence removes one risk factor from the total count.

Life-Habit Risk Factors

Obesity (BMI 30) Physical inactivity Atherogenic diet

Emerging Risk Factors

Lipoprotein (a) Homocysteine Prothrombotic factors Proinflammatory factors Impaired fasting glucose Subclinical atherosclerosis

FoamFoamCellsCells

FattyFattyStreakStreak

IntermediateIntermediateLesionLesion AtheromaAtheroma

FibrousFibrousPlaquePlaque

ComplicatedComplicatedLesion/RuptureLesion/Rupture

Endothelial dysfunction

Smooth muscleand collagen

From first decadeFrom first decade From third decadeFrom third decade From fourth decadeFrom fourth decade

Growth mainly by lipid accumulationThrombosis,haematoma

Adapted from Stary HC et al. Circulation 1995;92:1355-1374.

Atherosclerosis Timeline

Dislipidemia ----- Atherosclerosis ----- CVD A Progressive Disease

CRP=C-reactive protein; LDL-C=low-density lipoprotein cholesterol.

Libby P. Circulation. 2001;104:365-372; Ross R. N Engl J Med. 1999;340:115-126.

Monocyte LDL-C

Adhesion molecule

Macrophage

Foam cell

OxidizedLDL-C

Plaque rupture

Smooth muscle cells

CRP

Plaque instabilityand thrombusOxidationInflammationEndothelial

dysfunction

Atherothrombosis: Thrombus Superimposed on Atherosclerotic Plaque

Adapted from Falk E, et al. Circulation. 1995;92:657-671.

Myocardial Hypoxia

↓ ATP

Impaired Na+, K+ - ATPase ↑ Anaerobic metabolism

↑ Extracellular K+ ↑ Intracellular Na+ ↑ Intracellular Ca++

Altered membrane potential

Arrhytmias

Intracellular edema

↑ Intracellular H+

Chromatin clumpingProtein denaturation

CELL DEATH

↓ ATP↑ Proteases↑ Lipases

Adapted from Naik H, Sabatine MS, Lilly LS, 2007. Acute Coronary Syndrome. In: Lilly LS, ed. Pathophysiology of Heart Disease 4th Edition. USA: Lippincott Williams & Wilkins; 168-196

Pathology & ECG

Diagnosis of Acute MI STEMI / NSTEMI

At least 2 of the following

Ischemic symptoms

Diagnostic ECG changes

Serum cardiac marker elevations Time is muscle

Pemeriksaan Penunjang

1. EKG2. Enzim jantung

ECG assessment

ST Elevation or new LBBBST Elevation or new LBBBSTEMISTEMI

Non-specific ECGNon-specific ECGUnstable AnginaUnstable Angina

ST Depression or dynamicST Depression or dynamicT wave inversionsT wave inversions

NSTEMINSTEMI

Diagnosis Banding

1. perikarditis akut2. Emboli paru3. Diseksi aorta akut4. Kostokondritis5. Gangguan gastrointestinal

Acute Management

Initial evaluation & stabilization

Efficient risk stratification

Focused cardiac care

Chest pain suggestive of ischemia

12 lead ECG Obtain initial

cardiac enzymes electrolytes, cbc

lipids, bun/cr, glucose, coags

CXR

Immediate assessment within 10 Minutes

Establish Establish diagnosisdiagnosis

Read ECGRead ECG Identify Identify

complicationcomplicationss

Assess for Assess for reperfusionreperfusion

Initial labsInitial labsand testsand tests

Emergent Emergent carecare

History & History & PhysicalPhysical

IV accessIV access Cardiac Cardiac

monitoringmonitoring OxygenOxygen AspirinAspirin NitratesNitrates

Focused History Aid in diagnosis

and rule out other causes

Palliative/Provocative factors

Quality of discomfort Radiation Symptoms

associated with discomfort

Cardiac risk factors Past medical history

-especially cardiac

Reperfusion questions

Timing of presentation

ECG c/w STEMI Contraindication

to fibrinolysis Degree of STEMI

risk

Terapi

Aspirin 150-300 mg Clopidogrel 300 mg Oksigen 2-4 L Nitrat sublingual Morfin 2-5 mg intravena Penilaian dan stabilisasi hemodinamik Monitoring EKG Nilai kemunkinan reperfusi (fibrinolitik

atau PCI Primer)

Komplikasi

Aritmia Syok kardiogenik Edema paru akut Perikarditis

Prognosis

Killip TIMI Risk

DATA PRIBADI

Nama pasien : Tn. N. Pasaribu Umur : 49 Tahun Jenis kelamin : Laki-Laki Pekerjaan : Wiraswata Alamat : Desa Simorangkir Agama : Kristen Tanggal Masuk : 15 April 2011 Berat badan : 95 kg ; Tinggi badan :

176 cm

ANAMNESA KeluhanUtama : Nyeri dada Anamnese :

hal ini dialami pasien sejak 2 hari sebelum masuk rumah sakit. Nyeri seperti terbakar di dada kiri dan menjalar ke rahang bawah. Awalnya nyeri dirasakan setelah pasien berkebun. Nyeri tersebut tidak berkurang dengan beristirahat. Keringat dingin tidak dijumpai. Pasien mengeluh mual selama serangan, mual (-). Setelah 4 jam os merasakan nyeri yang terus-menerus, os berobat ke praktek dokter umum di Tarutung, dan os dinyatakan menderita sakit jantung. Os diberikan ISDN oleh dokter di Tarutung tersebut dan kemudian os dirujuk ke RS di Medan. Nyeri dirasakan sedikit berkurang setelah diberi ISDN. Kemudian os berobat ke praktek dr. P. ManikSp.JP(K) dan oleh dokter tersebut os dirujuk ke RS HAM. Saat tiba di UGD RS HAM, pasien masih mengeluhkan nyeri di dada kirinya. Riwayat sesak nafas, jantung berdebar, kaki bengkak, pingsan, dan batuk tidak ditemui.

Riwayat merokok dijumpai sejak kira-kira 25 tahun lalu, setengah bungkus per hari. Os sudah 8 tahun terakhir berhenti merokok. Konsumsi alkohol dan tuak dijumpai. Os menderita sakit asam urat selama 5 tahun ini

Faktor resiko PJK : laki-laki, obesitas, ex-smoker, DM (-), hipertensi (-), riwayat PJK dalam keluarga (-)

Riwayat Penyakit Terdahulu : asam urat Riwayat Pemakaian Obat : Tidak jelas

PEMERIKSAAN FISIK

KeadaanUmum : lemahStatus present : CMTD : 100/60 mmHgHR : 85 x/iRR : 24x/i

Temp : 36,5ºC

 

Anemia (-)

Sianosis(-)

Ikterus(-)

Dyspnoe(-)

Edema(-)

Ortopnoe(-)

Kepala: mata :konjungtivapalpebra inferior pucat (-/-), sclera ikterik (-/-), RC (+/+) pupil isokor ka=ki 

Leher : JVP R+2 cmH2O Thorax :

Inspeksi : Simetrisfusiformis Palpasi: SF ka = ki, kesannormal Perkusi : sonordikedualapanganparu Auskultasi : vesikuler

Jantung: Batas atas :ICS III sinistraBatas kanan:Linea sternalisdextra ICS VBatas kiri :1cm medial LMCS ICS V

S1 (N), S2 (N), S3 (-), S4 (-) Regulitas: reguler Murmur - Punctum maximum : -Radiasi: -

 

Paru: SP : vesikulerST :Rongkibasah(-)

wheezing (-)

Abdomen: Palpasi: soepel H/L/R : tidakterabapembesaran Asites: (-)

Ekstremitas : Superior : sianosis (-), clubbing finger (-) Inferior : oedemapretibial (-), pulsasiarteri

(+/+), akralhangat

Interpretasi EKGEKG TARUTUNG

SR, QRS rate 79x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III, AVF; Q path. : - , T inverted -, LVH -, RVH -, VES –

Kesan : SR + STEMI inferior

INTERPRETASI EKGEKG RS HAM (CVCU)

SR, QRS rate 64x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III, AVF; Q path. : III, AVF T inverted II, III, AVF; LVH -, RVH -

Kesan : SR + STEMI inferior

INTERPRETASI FOTO THORAX

CTR: 50%, Segemen Aorta danpulmonal : Normal, , PinggangJantung : (-), Apex downward, Kongesti (+), Infiltrat (-).

KESAN : normal

HASIL LABORATORIUM

DarahLengkap : Hb : 17 g %

Eritrosit : 5, 92 x 106/mm3

Leukosit : 14,4 x 103/mm3

Hematokrit : 52,9 % Trombosit : 223 x 103/mm3

AGDA : pH : 7,425 pCO2 : 32,1 mmHg pO2 : 108,9 mmHg HCO3 : 21,3 mmol/L Total CO2 : 21,5 mmol/L BE : -2,6 mmol/L SaO2 : 98,2%

FaalHati SGOT : 130 U/L SGPT : 46 U/L

Troponin– T : 1,8

CK-NAC :805

CK-MB :77

Glukosadarahsewaktu : 142 mg/dL

Ginjal Ureum : 36 mg/dL Kreatinin : 0,72 mg/dL

Elektrolitserum Natrium (Na) : 127

mEq/L Kalium (K) : 4,8 mEq/L Klorida (Cl) : 111 mEq/L

DIAGNOSADiagnosis kerja:

STEMI inferior onset 2 harikillip I TIMI risk 2/14

Fungsional : KILLIP I Anatomi: Right Coronary Artery Etiologi:arterosklerosis

PENGOBATAN Bedrestsemifowler O2 2-4 L/I Inj.enoxaparin0,6 cc/12

jam (5 hari) Clopidogrel 4x75mg,

selanjutnya 1x 75 mg Aspilet2x80mg,

selanjutya 1x 80 mg ISDN 3x5mg Simvastatin 1x40mg Captopril3x6,25mg Morfin 2,5 mg IV

RENCANA PEMERIKSAAN SELANJUTNYA

Lipid profile Angiografikoroner

PROGNOSIS

Vitam : dubia ad bonam

Functionam : dubia ad bonam

Sanactionam: dubia ad bonam

 FOLLOW UP EKG 13 April 2011 (RS TARUTUNG)

SR, QRS rate 79x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III, AVF; Q path. : - , T inverted -, LVH -, RVH -, VES –

Kesan: SR + STEMI inferior 15 April 2011 (IGD RS HAM, Pukul 18.11)

SR, QRS rate 69x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III, AVF; Q path. : III, AVF , T inverted II, III, AVF ;LVH -, RVH -, VES –

Kesan: SR + STEMI inferior 15 April 2011 (CVCU, Pukul 19.00)

SR, QRS rate 64x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III, AVF; Q path. : III, AVF T inverted II, III, AVF; LVH -, RVH -,VES-

Kesan: SR + STEMI inferior

16 April 2011 (Ruangan, Pukul 05.15)SR, QRS rate 63x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III, AVF; Q path. : III, AVF; T inverted II, III, AVF; LVH -, RVH -,VES-

Kesan : SR + STEMI inferior 18 April 2011 (Ruangan, Pukul 07.00)

SR, QRS rate 73x, QRS axis : normo axis, P wave (+) normal, PR interval 0.2”, QRS duration 0,08, ST elevasi : (-); Q path. : III , T inverted II, III, AVF; LVH -, RVH -, VES –

Kesan : SR + STEMI inferior

TERIMA KASIH