Presented by: Rezky F Saban (C11110103) Supervisor: Dr.dr. Idar Mappangara, Sp.PD,SpJP,FIHA,FINASIM. CARDIOLOGY DEPARTMENT MEDICAL FACULTY OF HASANUDDIN UNIVERSITY MAKASSAR 2015 ST ELEVATION MYOCARDIAL INFARCTION
Dec 25, 2015
Presented by: Rezky F Saban (C11110103)
Supervisor:Dr.dr. Idar Mappangara, Sp.PD,SpJP,FIHA,FINASIM.
CARDIOLOGY DEPARTMENTMEDICAL FACULTY OF HASANUDDIN UNIVERSITY
MAKASSAR 2015
ST ELEVATION MYOCARDIAL INFARCTION
PATIENT IDENTITY
Name : Mr. H
Age : 54 years old
Gender : Male
Address : Kutulu
MR : 698129
Date of Admission : January 22th 2015
HISTORY TAKING Chief Complaint : Chest Pain
Present Illnes History :
It was felt since 4 hours ago before he was admitted to the hospital. The pain felt like compress pain by weight thing, continous,not radiating and along with cold sweating.No dispnea,no dispnea on exertion,no orthopnea,no paroxysmal nocturnal dispnea, no cough,no fever,no nausea,no epigastric pain.Defecation and urination within normal limit.
PREVIOUS ILLNESS HISTORY
• No history of diabetes Mellitus• Nohistory of hypertension• No history of previous chest pain• No history of heart disease at the past
• No history of heart disease in the family•No history of drinking alcohol•No history of smoking
PHYSICAL EXAMINATION
General Status• Moderate illness/ Well nourished/ Compos mentis• Nutritional Status:
• Weight : 70 kg • Height : 170 cm • BMI : 24,22 kg/m2 (overweight)
Vital Sign • Blood Pressure : 110/60 mmHg • Pulse Rate : 71 bpm • Respiratory Rate : 22 bpm • Temperature : 36.5 0C (axilla)
Head and Neck Examination • Eye : Conjunctiva anemic (-/-),
Sclera icteric (-/-) • Lip : Cyanosis (-) • Neck : JVP R+1 cmH20
Thorax Examination• Inspection : Symmetric between left and right chest. • Palpation : No mass, no tenderness. • Percussion : Sonor between left and right chest, lung-liver
border in ICS VI right anterior. • Auscultation: Respiratory sound: Vesicular Additional sound : Ronchi -/- , Wheezing -/-
Heart examination :• Inspection : Apex invisible• Palpation : Apex impalpable• Percussion :
Upper heart : ICS II parasternalis linea sinistra
Bottom heart : ICS V parasternalis linea dextra
Left Heart : ICS V midclavicularis linea sinistra
Right heart : ICS IV parasternalis linea dextra • Auscultation : heart sounds I/II regular, murmur (-), gallop (-)
Abdomen Examination :• Inspection : flat, following breath movement • Auscultation : peristaltic sound (+), normal • Palpation : mass (-), pain (-), liver and lien impalpable • Percussion : tymphani (+), ascites (-)
Extremities Examination :• Oedema Pretibial -/-• Oedema dorsum pedis -/-
LABORATORY FINDING January 22th 2015 (1st day of treatment)
TEST RESULT NORMAL VALUE
GDS 160 mg/Dl <140
SGOT 29 u/L <38
SGPT 29 u/L <41
Ureum 35 10-50
Kreatinin 0,90 0,5-1,2
LABORATORY FINDING January 22th 2015 (1st day of treatment)
TEST RESULT NORMAL VALUE
Troponin I 0.12 <0,01
CK 129 <190
CKMB 27.3 <25
Natrium 139 136 - 145
Kalium 4,7 3,5 - 5,1
Klorida 106 97 - 111
Asam Urat 8.8 3,4-7,0
ECG INTERPRETATION• Interpretasi• Ritme : Sinus Rhytm• Heart Rate : 83 bpm• Axis : Normoaxis• P wave : 0,08s• PR Interval : 0,20s• QRS complex : 0,10s, • ST Segment : ST Elevation pada lead II, III, aVF• Conclusion : ST-Elevation Myocardial Infarction
Inferior• Conclusion : Sinus Rythm, HR 83 bpm, ST-Elevation
Myocardial Infarction Inferior
MANAGEMENT
• O2 4 lpm via nasal canule
• IVFD NacL 0,9 % 500 cc/24 hours• Actilyse 1 vial/syringe pump (15 mg over in 15 minute,
continue 35 mg over in 45 minute)• Aspilet 80mg/ 24 hours/ oral• Clopidogrel 75mg/ 24 hours/ oral• Atorvastatin 40mg/ 24 hours/ oral• Farsorbid 10mg/ 8 hours/ oral• Arixtra 2.5mg/ 24 hours/ subcutan• Laxadine 10cc / 24 hours/ oral• Alprazolam 0,5 mg/ 24 hours/ oral
DEFINITION• Myocardial infarction (MI) rapid development of myocardial
necrosis caused by a critical imbalance between the oxygen supply and demand of the myocardium.
• This usually results from plaque rupture with thrombus formation in a coronary vessels, resulting in an acute reduction of blood supply to a portion of the myocardium.
ACS describe a group of conditions resulting from acute myocardial
ischemia (insufficient blood flow to heart muscle) ranging from
unstable angina to myocardial infarction.
CLASSIFICATION
Diagnosis of ACS
1. Ischemic symptoms
2. Diagnostic ECG changes
3. Serum cardiac marker elevations
At least 2 of the following :
Difference Between cardiac chest pain and non cardiac chest pain• The classic presenting complaint of cardiac chest pain is
chest discomfort, which patients often describe as substernal ‘‘tightness,’’ ‘‘heaviness,’’ or ‘‘pressure.’’
Gender and Age
Men, increased risk age > 45 years
old
Women, increased risk age > 55
years old
Family History
RISK FACTORS
Non- Modified Modifiable
Smoking
Hypertension
Diabetis Mellitus
Dyslipidemia
Obesity
Lack of physical activity
ECG FindingsSite of infarction Sign of electrically inert
Myocardium
Anteroseptal V1-V3, sometimes V4
Anterior V2-V4. Late R progression in precordial leads.
Anterolateral V4-V6
Lateral V5-V6
Extensive Anterior V1-V6
High Lateral I, aVL
Inferior II, III, aVF
Inferolateral II, III, aVF and V5-V6
Posterior Initial R in V1, V2. >0.04s. R>S
Diagnose
No
Yes
YesNo
NSTEMI(No ST-Segment Elevation
Myocardial Infarction)
Unstable Angina
Signs of myocardial ischemia
ST segmen elevation ?
Biochemical cardiac markers ?
ECG
Lab
STEMIAcute Myocardial Infarction
( Q-wave, non-Q wave )
Prognosis
KILLIP CLASSIFICATION
Class
Description Mortality Rate (%)
I no 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
60 – 80
TIMI PROGNOSIS
Risk Factor Score
Age > 65 years old >/= 75
23
History of angina/hipertension/DM
1
Systolic BP <100 3
Heart rate >100 2
Killip II-IV 2
Weight >67 kg 1
Anterior MI or LBBB 1
Delay treatment >4 hours 1
Total Score
Risk of Death 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%