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STEMI EXTENSIVE ANTERIOR
> 24 HOUR ONSET KILLIP I
Presented by:
Andi Ita Maghfirah
Supervisor :Dr.dr.Idar Mappangara, Sp.PD, Sp.JP, FIHA,
FINASIM, FICA
Department of Cardiology and Vascular Medicine
Medical Faculty of Hasanuddin University
Makassar
2013
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PATIENT IDENTITY
Medical Record : 621999
Name : Mr. LH
Gender : Male
Age : 58 years old Address : Rajawali
Date of admission : August 9th
2013
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HISTORY TAKING
Chief complaint:
Chest Pain
History of Present Illness:
The chest pain began since 7 days before he was admitted to Wahidin
Sudirohusodo Hospital. Damning since 5 days ago. The sensation of chest pain
suddenly appeared when the patient was working. The pain is described like dull
heavy feeling on the left part of the chest, not spreading . The chest pain felt
continuously more than 20 minutes duration, and not relieved by rest. The chest
pain was accompanied with cold sweat and feeling nauseated. Theres no historyof any chest pain before. Theres also have hystory of hypertension since 10 years
ago, no history of fever and diabetes. History of any heart disease in the family
denied. Patient been smoking for almost 30 years with 12 cigarette each days .
Patient has history of epigastric pain. Urination and defecation were normal.
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HISTORY TAKING
History of Past Illness: History of chest pain (-)
History of smoking (+ ) for 30 years
History of hypertension (+) for 10 years
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
History of epigastric pain (+)
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RISK FACTOR
Gender: Male
Age: 58 yo
Non
Modifiable
Smoking (+)
Hypertension (+)
Obesity (+)
Modifiable
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PHYSICAL EXAMINATION
General Status
Moderate illness/normal weight/conscious
Vital Signs
BP : 140/90 mmHg
HR : 98 bpm, regular
RR : 20 tpm
Temp : 36.6CWeight : 64 kg
Height : 158 cm
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PHYSICAL EXAMINATION
Head Examination
Eyes : Anemic -/-, Icterus -/- Lips : Cyanosis (-)
Neck : Lymphadenopathy (-), JVP R+0 cmH2O
Thorax Examination
Insp. : Symmetrical R=L , normochest Palp. : Mass (-), tenderness (-), Vocal Fremitus
R=L
Perc. : Sonor
Ausc. : Vesicular
Ronchi -/-,Wheezing -/-
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PHYSICAL EXAMINATION
Cardiac Examination Insp. : IC not visible
Palp. : IC not palpable
Perc. : Dull
Right border : Right
parasternalis line
Left border : ICS 5midclavicularis line
Ausc. : Pure regular of I/II heart sound, murmur (-)
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ELECTROCARDIOGRAPHY
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ELECTROCARDIOGRAPHY
Interpretation:
Rhythm : Sinus ritme QRS-Rate : HR 100 bpm, reguler
P-Wave : 0.12 sec
PR-Interval : 0.20 sec
QRS Complex : 0.11 sec on v1
Axis : Normal axis 50 ST-Segment : ST-elevation on lead I, aVL, V2-V6
T-Wave : Normal
Conclusion: Sinus Rythmn, HR 100 bpm, normoaxis .ST-elevation on lead I ,aVL and lead V2-V6. complexQRS widen normal on v1, Acute Extensive MyocardiacInfarct
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LABORATORY EXAMINATION
WBC : 14.9
HB : 14,5 gr/dl
PLT : 258.000 HCT : 45,3 %
GDS : 108 mg/dl
Ureum : 38 mg/dl
Creatinin : 14 mg/dl
Uric acid : 6,1 mg/dl
CK : 398 U/L
CKMB : 26 U/L
Trop. T : >2.0
Na : 145 mmol/l K : 3,69 mmol/l
Cl : 107 mmol/l
SGOT : 163 U/L
SGPT : 398 U/L
PT : 12,4 control 10,5
APTT : 24,2 control 23,4
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DIAGNOSIS
- STEMI Extensive Anterior with >24
hour onset Killip I
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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
Anti Platelet Aggregation
ASA (Aspilet) loading dose 80 mg (2 x 80 mg)
maintenance 1-0-0
Clopidogrel (Plavix) loading dose 75 mg (4 x 75 mg) maintenance 0-1-0
Anti cholesterol
HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg) 0-0-1
Anti coagulant
Low Molecule Weight Heparin(Fondaparinux(Arixtra)) 2,5 mg/24 hr/SC
Anxiolytic
Benzodiazepin (Alprazolam 1 x 0,5 mg)
Laxative
Laxadin syrup 1 x 2 cth
Anti hypertension
Ace-inhibitor (Captopril) 3 x 12,5 mg
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PLANNING
Echocardiography
Coronary angiography
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ACUTE CORONARY
SYNDROME
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DIAGNOSIS OF CHEST PAIN
3 point typical chest painTend to be Stable Angina Pectoris than Acute CoronarySyndrome
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
activity oremotion
1point Relieved by
resting ornitrate SL
1point
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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).
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CLASSIFICATION
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PATHOPHYSIOLOGY
Vulnerable Plaque
Thrombosis
Vasospasme
Plaque disruption andthrombosis that result in
complete coronary
artery occlusion leads
to transmural ischemiaand necrosis, the
hallmark of ST-segment
elevation myocardial
infarction (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
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
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At least 2 of the following:
DIAGNOSIS OF ACS
1. Ischemic
symptoms
2. Diagnostic ECGchanges
3. Serum cardiacmarker elevations
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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
1. ISCHEMIC SYMPTOMS
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2. DIAGNOSTIC ECG CHANGES
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ECG CHANGESTiming of myocardial infarction based on ECG
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3. SERUM CARDIAC MARKER
ELEVATIONS
TroponinT CK-MB CK
SGOT LDH Myoglobin
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CARDIAC BIOMARKER
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DIAGNOSIS
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WHO DIAGNOSTIC CRITERIA
Clinical history of ischaemictype chest pain lasting >20minutes
Changes in serial ECG tracings
Rise of serum cardiacbiomarkers such as creatininekinase-MB fraction and troponin
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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 not
sustained, 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 continued
indefinetely
Clopidogrel 300-600 mg loading dose and 75 mg daily continued for at least
14 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 CLASSIFICATION
Class Description Mortality Rate (%)
I No clinical signs of heart failure 6
IIRales or crackles in the lungs, an S3,
and elevated jugular venous pressure17
III Acute pulmonary edema 30 - 40
IV
Cardiogenic shock or hypotension
(systolic BP < 90 mmHg), and
evidence of peripheral vasoconstriction
60 80
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THANK YOU