ANTEROSEPTAL WALL STEMI WITH ONSET 12 HOURS KILLIP IISupervisor: dr. Abdul Hakim Alkatiri, SpJP .FIHACARDIOLOGY DEPARTMENTMEDICAL FACULTYMAKASSAR2015Presented by:Muhamad Faiz bin Mohd NazriC11110867CARDIOLOGY DEPARTMENT

PATIENTS IDENTITYNAME : Mrs. SPAGE : 67 years oldGENDER: FemaleMR: 70-74-45Day of Admission : April 8th, 2015

HISTORY TAKINGCHIEF COMPLAINT: Chest pain Structural Anamnesis: It was felt 1 day (onset 12 hours since 9 pm) before admitted to the hospital. The pain was felt on the left side of the chest with the characteristics of dull heavy feeling of the chest, duration of pain was > 30 minutes, radiated to the left arm and to the back. The pain exacerbated with exercises and did not lessen with rest or medication. Chest pain accompanied by shortness of breath. Dyspnea on effort (+) Orthopnea (-) Paroxysmal Nocturnal Dyspnea (-) Patient usually slept with 1-2 pillows. Cough (-) Fever (-) Nausea (+) Vomit (+) Palpitation (-) Cold sweats (+)

PAST MEDICAL HISTORYHistory of diabetes melitus (-)History of hypertension (+) since 1 year ago with uncontrolled therapy.History of smoking (-)History of cardiovascular disease in family (-)

RISK FACTORSCigarette smoking (-)Alcohol consumption(-)Hypertension(+)Diabetes (-)History of Cardiovascular disease (-)Thyroid disease (-)History of cardiovascular disease and thyroid disease in family (-)

PHYSICAL EXAMINATIONGeneral Status:Moderate illness/ Well nourished/ ConsciousNutritional Status: Normal (BMI: kg/m)Weight : 60 kg BMI: 23.4 kg/m2Height : 160 cm

Vital Signs:Blood Pressure: 170/110 mmHgPulse Rate: 68 tpmRespiratory Rate : 20 tpmTemperature : 36.7 0C

Head and Neck Examinations:Eye : Conjunctiva: anemic (-/-), Sclera: icteric (-/-) Lip : Cyanosis (-)Neck : JVP R +2 cmHO

Chest ExaminationInspection: Symmetric between left and right chest.Palpation: No mass, no tenderness.Percussion: Sonor between left and right chest, lung- liver border in ICS IV right anterior .Auscultation: Respiratory sound: Vesicular Additional sound: Ronchi +/+,Wheezing -/-

Cardiac ExaminationInspection: invisible heart apex Palpation : Heart apex was not palpable Percussion: Right heart border in right parasternal line, one finger lateral from left medioclavicular lineAuscultation: Heart Sounds : S I/II regular, murmur (-) gallop(-)

Abdominal ExaminationInspection: Flat, following breath movementAuscultation: Peristaltic sound (+), normalPalpation: No mass, no tenderness, no palpable liver or spleen.Percussion: Tympani (+)

Extremities ExaminationPretibial edema -/-Dorsal pedis edema -/-

ECG InterpretationRhythm : Sinus RhythmHR / QRS rate: 83 times/minAxis : NormalRegularity : RegularP wave : 0,08 sPR interval : 0,2sQRS complex : 0,16 sST segment: ST elevation at V1-V4T wave: T inverted on lead II,III, aVF

Conclusion : Sinus rhythm, HR 83 times/min, normoaxis, anteroseptal infarction and ishemic pada inferior

LABORATORY FINDINGS (07/04/2015)COMPLETE BLOOD COUNT

TestResultNormal valueWBC4.20 x 103/ul4.0 10.0 x 103RBC4.06 x 106/l4.0 6.0 x 106HGB11.2 gr/dl12 16 HCT34.4 %37 48 PLT209 x 103 /l150 400 x 103

LABORATORY FINDINGS (07/04/2015)BLOOD CHEMISTRY

TestResultNormal valueGDS124 mg/dl

LABORATORY FINDINGS (07/04/2015)CARDIAC ENZYMES

TestResultNormal valueCK733.00U/L

CHEST X-RAYS 07/04/2015Conclusion: Cardiomegaly Dilatation and elongation of aorta.

WORKING DIAGNOSISANTEROSEPTAL WALL STEMI WITH ONSET 12 HOURS KILLIP II

MANAGEMENTO2 2 -4 Lpm IVFD NaCl 0,9% 500cc/dayCedocard 1 mg/hour/SP NitratArixtra 2,5 mg/24 hour/sc LMWH (Low Molecule Weight Heparin)Aspilet 80 mg 0-0-1 Aspirin (Antiplatelet)Clopidogrel 75 mg 0-0-1 Clopidogrel (Antiplatelet)Captopril 6.25 mg 1-1-1 ACE-InhibitorSimvastatin 40 mg 0-0-1 Statin (Anticholesterol)Laxadyn syr 0-0-2c LaxativeAlprazolam 0,5 mg 0-0-1 AntianxietasFluid balance

PLANNINGECG per day

Discussion

ST ELEVATION MYOCARDIAL INFARCTION

INTRODUCTIONMyocardial ischemia is caused by imbalance between myocardial oxygen supply and myocardial oxygen consumption.Myocardial infarction (MI) is the rapid development of myocardial necrosis.

An acute myocardial infarction is caused by necrosis (irreversible) of myocardial tissue due to ischemia, usually due to blockage of a coronary artery by a thrombus.European Heart Journal. Guidelines on the management of stable angina pectoris

European Heart Journal. Guidelines on the management of stable angina pectoris

LateralI, AVL,V5-V6Anterior / SeptalV1-V4InferiorII, III, aVFRegions of the Myocardium

PATHOPHYSIOLOGYOccurs 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.

CLASSIFICATION

DIAGNOSISOxford Handbook of Clinical Medicine 6th Edition

CARDIAC BIOMAKERS

RISK FACTORSModifiable:

HypertensionDiabetes MellitusDyslipidemiaSmokingObesityNon-modifiable:

Gender: maleAge >45 years oldPersonal history of Coronary Artery DiseaseFamily history of Coronary Artery Disease

Ischemic symptomsProlonged pain (usually >20 mins) constricting, crushing, squeezing Usually retrosternal location, radiating to left chest, left arm; can be epigastric Dyspnea Diaphoresis Palpitations Nausea/vomiting Light headedness Sense of impending doom

DIAGNOSE????

KILLIP CLASSIFICATION

ClassDescriptionMortality Rate (%)Ino clinical signs of heart failure6IIrales or crackles in the lungs, an S3, and elevated jugular venous pressure17IIIacute pulmonary edema30 - 40IVcardiogenic shock or hypotension (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction60 80

Relieve pain Hemodinamic stabilitation Miokardial reperfusion Prevent the complicationKabo P. Bagaimana menggunakan obat-obat kardiovaskular secara rasional. 2010

Kabo P. Bagaimana menggunakan obat-obat kardiovaskular secara rasional. 2010

Managing chest pain and anxietyBed restDiet O2 2-4 lpmNitrate sublingual/oral/IVAntiplatelet: aspirin and clopidogrelMorphine/ pethidineStabilizing hemodynamic (blood pressure and peripheral pulse control)-blockerCalcium channel blocker (CCB)ACE-InhibitorReperfusion of the myocardiumThrombolytic

THERAPY

COMPLICATION of MYOCARDIAL INFARCTION

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