STEMI Whole Anterior Onset

7/22/2019 STEMI Whole Anterior Onset

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Presented by:

Anneke Holly

Supervisor :

Dr. dr. Idar Mappangara, Sp. PD, Sp.JP, FIHA, FINASIM

Whole Anterior Wall STEMI

Onset >12 hours KILLIP I TIMI Score 2/14

Department of Cardiology and Vascular Medicine

Medical Faculty of Hasanuddin University

Makassar2013


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PATIENT IDENTITY

Medical Record : 624852

Name : Mr. A

Gender : Male

Age : 64 years old

Address : Mandai

Date of admission : 27thAugust 2013


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HISTORY TAKING Chief Complaint:

Chest Pain

History of Present Illness:

The chest pain began since 14 hours ago before he was

admitted to Wahidin Sudirohusodo Hospital. The sensation of chest

pain suddenly appeared when the patient was subuh pray. The chest

pain felt continuously more than 30 minutes duration, and not relieved

by rest. The pain is described like dull heavy feeling on the left chest,

radiated to his back, shoulder and left hand. The chest pain wasaccompanied with cold sweat and tightness sensation. The patient

felt nausea and not vomiting.

The patient feel breathlessness while having chest pain, and it

accompanied by palpitation and cold sweat. He never wakes up from

his sleep in the night because of breathlessness. He could sleep with


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HISTORY TAKING

History of Past Illness: History of chest pain before (-)

History of smoking ( + ) 1 packs/day two years ago, but

now he smokes 2 pieces/day

History of hypertension : denied

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

No history of epigastric pain


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RISK FACTOR

Gender: Male

Age : 64 years old

Non

Modifiable

Smoking (+)

Modifiable


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PHYSICAL EXAMINATION

General StatusModerate Illness/ Well-nourished /Compos

Mentis

Vital Signs BP : 110/70 mmHg HR : 75 bpm, regular RR : 22 tpm T : 36.7C BW : 65 kg H :170 cm


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Head Examination Eyes : Anemic -/-, Icterus -/-

Lips : Cyanosis (-)

Neck : Lymphadenopathy (-), JVP R+1

cmH2O

Thorax Examination Insp. : Symmetrical R=L, normochest

Palp. : Mass (-), tenderness (-), VF R=L

Perc. : Sonor Ausc. : Vesicular

Ronchi -/-,

Wheezing -/-


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Cardiac Examination

Insp. : IC wasnt visible

Palp. : IC wasnt palpablePerc. : Dull, normal heart sizeRight border : Right parasternalis line

Left border : Left medioclavicularis line

Ausc. : Pure regular of I/II heart

sound, murmur (-)


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Abdominal Examination

Insp. : Flat and following breath

movement

Ausc. : Peristaltic sound (+), normal Palp. : Liver and spleen is unpalpable

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

Extremities

Oedema : Pretibial -/-, Dorsum pedis -

/-


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ELECTROCARDIOGRAPH

Y

Wide QRS

Slurred S


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ELECTROCARDIOGRAPHY


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ELECTROCARDIOGRAPHY Interpretation:

Rhythm : Sinus

Heart Rate : 75 bpm,

Regularity : Regular

P-Wave

Configuration : Normal configuration

Duration : 0.08 sec

PR-Interval : 0.16 sec

QRS Complex Configuration : Q wave formations on lead V2, V3, V4, and V5

Duration : 0.08 - 0.16 sec (Wide QRS on lead V1)

Axis : -160(RAD)

ST-Segment :

ST-elevation on lead V2, V3, V4, and V5

Slurred S on lead V6

T-Wave : Normal

Conclusion:

Sinus Rhythm, RAD, CRBBB, Whole Anterior wall STEMI.


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CHEST X-RAY

Normal pulmonary

CTI: Normal

Result: Normal Pulmo


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LABORATORY EXAMINATIONLaboratory Test ( 27-8-2013)

Result Normal Range Unit

WBC 15.8 4.0-10.0 103/mm3

RBC 4.83 4.50-6.50 106/mm3

HGB 14.8 14.0-18.0 g/dL

HCT 45.2 40.0-54.0 %

PLT 321 150-400 103/mm3

PT 10.2 control 11.9 10-14 Seconds

APTT 27.2 control 26.4 22.0-30.0 SecondsINR 0.80 - -

Natrium 143 136-145 mmol

Kalium 4.3 3.5-5.1 mmol

Chloride 109 97-111 mmol

GDS 126 140 mg/L

Ureum 25 10-50 mg/L

Creatinine 0.6 M


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LABORATORY

EXAMINATION

Laboratory Test (29-8-2013)

Total Cholesterol 186 200 mg/dL

HDL 45 M>55; F>65 mg/dL

LDL 126 2.0


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DIAGNOSIS

Whole Anterior Wall STEMI onset >12

hours KILLIP I TIMI Score 2/14


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INITIAL MANAGEMENT

Bed rest

O22-4 LPM (via nasal canule)

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

ISDN

Cedocard 0,5 mg/hour/SP 2,5 cc/hour/sp

Anti Platelet Aggregation ASA (Aspilet) loading dose 160 mg single dose; Maintenance 1-0-0 (80

mg)

Clopidogrel (Plavix) loading dose 300 mg single dose; Maintenance 0-

1-0 ( 75 mg)

Anti cholesterol HMG-Co A reductase inhibitor (Simvastatine 1 x 20 mg)

Anxiolytic

Benzodiazepine (Alprazolam 1 x 0,5 mg)

Laxative

Laxadine syrup 1 x 2 cth


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PLANNING

Monitoring Electrocardiography

Echocardiography

Coronary angiography


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ACUTE CORONARYSYNDROME


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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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MYOCARDIALINFARCTION


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DEFINITION

Myocardial infarction (MI) is rapiddevelopment of myocardial necrosis caused

by imbalance oxygen supply and demand

of the myocardium.

It results from plaque rupture with thrombus

formation in a coronary vessels, resulting in

an acute reduction of blood supply to a partof the myocardium.


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PATHOPHYSIOLOGY

Vulnerable Plaque

Thrombosis

Vasospasme

Plaque disruption andthrombosis that resultin complete coronaryartery occlusion leadsto transmural ischemia

and necrosis, thehallmark of ST-segment elevationmyocardial 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

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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WHO DIAGNOSTIC

CRITERIA

Clinical historyof ischaemictype chest pain lasting >20minutes

Changesin serial ECGtracings

Riseof serum cardiacbiomarkerssuch as creatininekinase-MB fraction and troponin


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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


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2. DIAGNOSTIC ECG

CHANGES


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ECG CHANGESTiming of myocardial infarction based on ECG


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CARDIAC BIOMARKER


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CLINICAL HISTORY

Duration: variable, often more than 30minutes.

Quality: Feels squeezing, pressurelike,

tightness, heaviness, and burning.

Location: Retrosternal, often with radiation

to or isolated discomfort in neck, jaw,

shoulders, or armsfrequently on left.

Associated features : Not relieve with restor nitrat


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o

Yes

Yeso

STEMIAcute Myocardial Infarction

( Q-wave, non-Q wave )

NSTEMI(No ST-Segment Elevation

Myocardial Infarction)

Unstable Angina

Signs of myocardial ischemia

ST segmen elevation ?

Biochemical cardiac markers ?

DIAGNOSIS

ECG

Lab


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DIAGNOSIS


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Prognosis KILLIP classification

Clas

sDescription

Mortality Rate

(%)

INo clinical signs of heart

failure

6

II

Rales 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


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PROGNOSISTIMI SCORE

HistoricalAge 65-74

>/= 75

2 points

3 points

DM/HTN or Angina 1 point

ExamSBP < 100 3 points

HR > 100 2 points

Killip II-IV 2 points

Weight > 67 kg 1 pointPresentationAnterior STE or LBBB 1 point

Time to treatment > 4 hrs 1 point

Risk Score = Total (0-14)

Total

Score

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%


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THANK YOU

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STEMI Whole Anterior Onset

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