8/10/2019 Stemi UH

1/39

ST SEGMENT ELEVATION

MYOCARDIAL INFARCTION(STEMI)

PRESENTED BY :

AGUS RIANSYAH

C 111 10 335

SUPERVISED BY :

Dr. dr. Khalid Saleh, Sp.PD-KKV, FINASIM

Department of Cardiology and Vascular Medicine

Medical Faculty of Hasanuddin University

Makassar2015

8/10/2019 Stemi UH

2/39

PATIENT IDENTITY

ID Number : 691092

Name : MR S

Age : 55 years old

Gender : Male

Date of Admission : December 26th

2014

8/10/2019 Stemi UH

3/39

HISTORY TAKINGChief complaint : Shortness of breath

History of present illness

Experienced since 6 days ago before entering the hospital. Perceived

continuously, shortness experienced when the patient lying supine,

become heavy at night and when the patient activity. Historyshortness previously existed> 4 years ago.

If the patient shortness of breath regularly use spirocen and

shortness reduced. Starting 6 days ago the patient when taking

spirocen tightness but no change and increasingly crowded. Thepatient complained of chest discomfort there since 3 hours ago,

pain like like downtrodden. There is cold sweat. Nausea and vomiting

denied. No Fever and there is no previous history of fever. There is

no heartburn .

8/10/2019 Stemi UH

4/39

Past Ilness history

No History of Hypertension

No History of DM

No History of high blood cholesterol

No History of previous heart diseaseHistory of asthma when the patien elementary school

Family history

No family history of heart disease

Personal history:History of smoking two pack each day for more

30 years.

No history of drinking alcohol

HISTORY OF DISEASE

8/10/2019 Stemi UH

5/39

Modifiable

- Smoker

NonModifiable

- Gender : male (+)

- Age : 55thyears old (+)

RISK FACTOR

8/10/2019 Stemi UH

6/39

PHYSICAL EXAMINATION

General status

Moderate illness/wellnourished/compos

mentis

Vital sign BP: 140 / 90 mmHg

HR: 96 x/min

RR: 22 x/min

T : 36.70 C

8/10/2019 Stemi UH

7/39

REGIONAL STATUS

Head Examination Eyes : anemia (-), icterus (-)

Lip : cyanosis (-)

Neck : lymphadenopathy (-), JVP R+3 cmH2O

Thoracal Examination

Inspection : symetric, normochest

Palpation : mass (-), tenderness (-), VF R=L

Percussion : sonor

Auscultation : breath sound bronchovesicular,

there are minimally ronchi in a basal lung, wheezing-/-

8/10/2019 Stemi UH

8/39

Heart Examination Inspection : IC wasnt visible

Palpation : IC wasnt

palpable

Percussion : normal heart

size Upper border: left 2ndICS

Lower border : left 5th

ICS

Right border : right

parasternalis line Left border : left axillaris

anterior line

Auscultation : Regular of I/II

heart sound, murmur (-)

Abdominal Examination Inspection : flat and

following breath

movement

Auscultation: peristaltic

sound (+) , normal

Palpation : liver and

spleen unpalpable

Percussion : tympani,

ascites (-)

Extremities

Oedema : pretibial (-),

dorsum pedis (-)

REGIONAL STATUS

8/10/2019 Stemi UH

9/39

ELECTROCARDIOGRAPHY

(ECG)

8/10/2019 Stemi UH

10/39

8/10/2019 Stemi UH

11/39

INTERPRETATION Rhythm : Sinus Rhythm

Heart rate : 102 bpm

Regularity : regularly

Axis : LAD, -40o

P wave : 0.04sec

PR interval : 0.2 sec QRS complex: duration 0.08 sec,

ST Segment : ST elevation at V1, V2, V3, V4

ST depresi at I, aVL

T wave : Normal Conclusion : Sinus takikardi, LAD, Infark

anteroseptal wall,

Ischemic lateral wall

8/10/2019 Stemi UH

12/39

LABORATORY EXAMINATION

Completeblo

od

WBC : 5,1 x 103

HGB : 11,5 g/dl

PLT : 407 x 103/mm3

Cardiac enzyme

CK : 84 u/L

CK MB : 18,0 u/L

Troponin T : 0,33u/L

Electrolyte

Natrium :138mmol/l

Kalium : 3,9 mmol/l

Chloride : 96 mmol/l

Bloodche

mistry

GDS : 110mg/dl

SGOT : 27 u/l

SGPT : 22 u/l

Ureum : 13

Creatinin : 0,7

PT : 10,9

APTT : 25,7

INR :0,91

Uric acid: 4,6

8/10/2019 Stemi UH

13/39

Planning

ECG everyday

Echocardiography

Ro Thorax

Coronary Angiography

8/10/2019 Stemi UH

14/39

WORKING DIAGNOSISRecent STEMI Anterior, KILLIP II

8/10/2019 Stemi UH

15/39

MANAGEMENT O22 LPM (via nasal canule)

Cardiac Diet

IVFD NaCl 0,9% loading 500 cc/24 hours

Anti Agregasi Platelet

ASA (Aspilet) 80 mg (2 tab) / 24jam/ oral

Clopidogrel 75 mg/24 jam/oral

Anti c oagulan

Arixtra 2,5mg/24jam/subkutan

Nitrat

Farsorbid 10mg/8jam/oral

Anti Hipertensi

ACE-I (Captopril) 12,5 mg 1-1-1

Anti Kolesterol

HMG-Co A reductase inhibitor (Simvastatin) 20 mg 0-0-1

Diuresis

Furosemid 20mg/12jam/iv

Laksatif

Laxadin syrup 0-0-2 cth

8/10/2019 Stemi UH

16/39

ACUTE CORONARYSYNDROME

ST SEGMENT ELEVATION MYOCARDIAL

INFARCTION

DISCUSSION

8/10/2019 Stemi UH

17/39

8/10/2019 Stemi UH

18/39

ANATOMY

8/10/2019 Stemi UH

19/39

DIAGNOSIS OF CHEST PAIN

3 pointtypical chest painTend to be Stable Angina Pectoris than Acute Coronary Syndrome

2 point atypical chest pain

Tend to be Acute Coronary Syndrome than Non Cardiac Chest Pain

1 point or none non cardiac chest pain

Retrosternalor substernalchest pain

1point Increased by

activity oremotion

1point Relieved by

resting ornitrate SL

1point

8/10/2019 Stemi UH

20/39

CAD

ACS

UAP NSTEMI STEMI

StableAnginaPectoris

8/10/2019 Stemi UH

21/39

PATHOPHYSIOLOGY

8/10/2019 Stemi UH

22/39

Lipid transport disorder Inflamation

Plaque deposition

Stable plaque Plaque ruptureErosion

Stable angina pectoris

Thrombosis

Thrombus

Acute coronary syndrome:

Unstable angina

Myocardial infarction :

- Non Q waves- Q waves

8/10/2019 Stemi UH

23/39

8/10/2019 Stemi UH

24/39

At least 2 of the following:

DIAGNOSIS OF ACS

1. Ischemicsymptoms

2. Diagnostic ECGchanges

3. Serum cardiacmarker elevations

8/10/2019 Stemi UH

25/39

1. Ischemic Symptoms

8/10/2019 Stemi UH

26/39

2. Diagnostic ECG Changes

Acute inferior MIFrank G.Yanowitz, M.D.

o Acute inferior wall ST segment elevation MI (STEMI); note ST segment elevation in

leads II, III, aVF, ST segment depression in V1-3 represents true posterior injury.

8/10/2019 Stemi UH

27/39

ECG evolution for MI

Tall T wave. Minutes to

hours

ST-segment elevation.

Within hours. Last for 2

weeks.(>2 weeks ?)

Abnormal Q wave. Hours to

days. Persist.

ST-segment decline. With orafter the onset of T

inversion. Months to years or

persist.

Persistent Q wave

8/10/2019 Stemi UH

28/39

3. Serum Cardiac Marker

Elevations

Troponin T

CK-MB

CK

Myoglobin

8/10/2019 Stemi UH

29/39

RISK FACTOR FOR ACS

8/10/2019 Stemi UH

30/39

8/10/2019 Stemi UH

31/39

8/10/2019 Stemi UH

32/39

8/10/2019 Stemi UH

33/39

INDICATION

THROMBOLYTIC

Indication for Thrombolytic therapy:

1. ST-segment Elevation Myocardiac

Infarction (STEMI)2. Onset < 12 hours

3. No contraindication for thrombolytic

therapy

4. Chest pain >20 minutes, and not

relieved with nitrate administration

8/10/2019 Stemi UH

34/39

TROMBOLYTIC THERAPY

Perfusion indicator:

1. Non-Angiographic indicators:Decrease chest pain

Normal ST segmentPerfusion arrhythmia

2. Angiographic indicators:TIMI grade flow by using contrast coronary

angiography

8/10/2019 Stemi UH

35/39

COMPLICATION

Arrythmia Heart failure Cardiogenic shock

Rupture ofventricle

septum/wall

Rupture ofchordae tendineae

Pericarditis

Tromboemboli

8/10/2019 Stemi UH

36/39

Prognosis

KILLIP CLASSIFICATION

Class DescriptionMortality Rate

(%)

I No clinical signs of heart failure 6

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

venous pressure

17

III Acute pulmonary edema 30 - 40

IV

Cardiogenic shock or

hypotension (systolic BP < 90

mmHg), and evidence of

peripheral vasoconstriction

6080

8/10/2019 Stemi UH

37/39

PrognosisTIMI SCORE

HistoricalAge 65-74

>/= 75

2 points

3 points

DM/HTN or Angina 1 point

Exam

SBP < 100 3 points

HR > 100 2 points

Killip II-IV 2 points

Weight > 67 kg 1 point

PresentationAnterior STE or LBBB 1 point

Time to treatment > 4 hrs 1 point

Risk Score = Total (0-14)

TotalScore

Risk ofDeath in 30

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%

8/10/2019 Stemi UH

38/39

8/10/2019 Stemi UH

39/39