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Stemi Inferoposterior et RV
Onset 3 Hours Killip I
Presented by:
Muh. Ayyub Primadi
Supervisor :
dr. Abdul Hakim Alkatiri, Sp.JP, FIHA
Department of Cardiology and Vascular MedicineMedical Faculty of Hasanuddin University
Makassar
2013
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PATIENT IDENTITY
Medical Record : 622664
Name : Mr. R
Gender : Male Age : 31 years old
Address : Maros
Date of admission : 13 Agustus 2013
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HISTORY TAKING Chief complaint:
Chest Pain
History of Present Illness:
The chest pain began since 3 hours ago before he was admitted to Wahidin
Sudirohusodo Hospital. The sensation of chest pain suddenly appeared when the patient
was resting at home. The pain is described like dull heavy feeling on the left chest, radiated
to his back, shoulder and left hand. The chest pain was accompanied with cold sweat and
tightness sensation. The patient felt nausea and not vomiting. The chest pain felt
continuously more than 20 minutes duration, and not relieved by rest.
The patient felt breathlessness while having chest pain, and it was accompanied by
palpitation and cold sweat. He never wakes up from her sleep in the night because of
breathlessness. He could sleep with 1 pillow only. There was no cought and fever. No
history of epigastric pain. Urination and defecation were normal.
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HISTORY TAKING
History of Past Illness: History of chest pain before (-)
History of smoking ( + ) 2 packs/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
Non
Modifiable
Smoking (+)
Obesitas (+)
Modifiable
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PHYSICAL EXAMINATION
General Status
Moderate illness/obes 1/conscious
Vital Signs
BP : 130/80 mmHg
HR : 70 bpm, regular
RR : 22 tpm
T : 36.7C
BW : 82 kg
H :170 cm
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PHYSICAL EXAMINATION
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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PHYSICAL EXAMINATION
Cardiac Examination
Insp. : IC wasnt visible Palp. : IC wasnt palpable
Perc. : Dull, normal heart size
Right border : Right parasternalis line
Left border : Left medioclavicularis line
Ausc. : Pure regular of I/II heart sound, murmur
(-)
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PHYSICAL EXAMINATION
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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ELECTROCARDIOGRAPHY
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ELECTROCARDIOGRAPHY
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ELECTROCARDIOGRAPHY
Interpretation:
Rhythm : Sinus
QRS-Rate : HR 75 bpm, reguler
P-Wave : 0.08 sec
PR-Interval : 0.16 sec
QRS Complex : 0.08 sec
Axis : 120
ST-Segment : ST-elevation on lead II, III, aVF, V3R, V4R, V5R, V6R, V8, and V9.ST-depretion on lead V2, V3, V4, V5, and V6
T-Wave : Normal
Conclusion: Sinus Rhythm, HR 75 bpm, RAD, inferoposterior and right ventricular acute myocardialinfarction, whole anterior ischaemic.
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CHEST X-RAY
14 Agustus 2013
Normal pulmonary
CTI: Normal
Result: Normal Pulmo
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LABORATORY EXAMINATION
WBC : 23,7 x 103/mm
HB : 16,4 gr/dl
PLT : 312.000
HCT : 49,7 %
GDS : 123 mg/dl
Ureum : 15 mg/dl
Creatinin : 0,8 mg/d
PT : 21,7 (0,8)
APTT : 52,4 (26,6)
CK : 281 U/L
CKMB : 22 U/L
Trop. T : 0,02 Na : 141 mmol/l
K : 4,2 mmol/l
Cl : 107 mmol/l
SGOT : 31 U/L SGPT : 34 U/L
Albumin : 4,0 gr/dl
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DIAGNOSIS
- STEMI Inferioposterior + Right
Ventricular onset 3 hours KILLIP I
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INITIAL MANAGEMENT
Bed rest
O2 2-4 LPM (via nasal canule)
IVFD NaCl 0,9% loading 500 cc/24 hours
Anti Platelet Aggregation
ASA (Aspilet) loading dose 160 mg (2 x 80 mg) maintenance 1-0-0
Clopidogrel (Plavix) loading dose 300 mg (4 x 75 mg)maintenance 0-1-0
Anti cholesterol
HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg)
Trombolitik
Streptokinase (Streptase 1,5 million units were dissolved in 100 ml of
Dextrose 5% in drips for 1 hour) Anxiolytic
Benzodiazepin (Alprazolam 1 x 0,5 mg)
Laxative
Laxadin syrup 1 x 2 cth
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ELECTROCARDIOGRAPHY
Post Trombolitik
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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 Coronary
Syndrome
2 point atypical chest painTend 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
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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 incomplete coronaryartery occlusion leads totransmural ischemia and
necrosis, the hallmark ofST-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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At least 2 of the following:
DIAGNOSIS OF ACS
1. Ischemic symptoms
2. Diagnostic ECG changes
3. Serum cardiac marker 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
Troponin T CK-MB CK
SGOT LDH Myoglobin
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CARDIAC BIOMARKER
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No
Yes
YesNo
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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MYOCARDIAL INFARCTION
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DEFINITION
Myocardial infarction (MI) is rapid development 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 part of the
myocardium.
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PATHOPHYSIOLOGY
Vulnerable Plaque Thrombosis
Vasospasme
Plaque disruption and
thrombosis that result in
complete coronary artery
occlusion leads to
transmural ischemia andnecrosis, the hallmark of
ST-segment elevation
myocardial infarction
(STEMI)
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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
Changes in serial ECG tracings
Riseof serum cardiacbiomarkerssuch as creatininekinase-MB fraction and troponin
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CLINICAL HISTORY
Duration : variable, often more than 30 minutes.
Quality : Feels squeezing, pressurelike, tightness,
heaviness, and burning.
Location : Retrosternal, often with radiation to orisolated discomfort in neck, jaw, shoulders, or arms
frequently on left.
Associated features : Not relieve with rest or nitrat
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ECG CHANGESTiming of myocardial infarction based on ECG
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CARDIAC BIOMARKER
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DIAGNOSIS
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THROMBOLYTIC AGENTINDICATIONS
Age < 70 yo
Typical chest pain, > 20 minutes, not
relieved by nitrat
ST elevation > 0,1 mV, on 2 lead or more
Onset < 12 hours
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THROMBOLYTIC AGENT
Absolute: Previous intracranial
haemorrhage or stroke ofunknown origin at any time
Central nervous systemdamage or neoplasms
Recent majortrauma/surgery/head injury(within the preceding 3 weeks)
Gastrointestinal bleeding
within the past month Known bleeding disorder
(excluding menses)
Aortic dissection
Relative: Transient ischaemic attack in
the preceding 6 months
Oral anticoagulant therapy
Pregnancy or within 1 weekpostpartum
Refractory hypertension(systolic blood pressure >180mmHg and/or diastolic bloodpressure >110 mmHg)
Advanced liver disease
Infective endocarditis
Prolonged or traumaticresuscitation
CONTRAINDICATIONS
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PROGNOSIS
KILLIP CLASSIFICATION
Class DescriptionMortality Rate
(%)
I No clinical signs of heart failure 6
IIRales or crackles in the lungs, anS3, and elevated jugular venous
pressure
17
III Acute pulmonary edema 30 - 40
IV
Cardiogenic shock orhypotension (systolic BP < 90
mmHg), and evidence of
peripheral vasoconstriction
60 80
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PROGNOSIS TIMI 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 point
PresentationAnterior STE or LBBB 1 point
Time to treatment > 4 hrs 1 point
Risk Score = Total (0-14)
Total
Score Risk of Deathin 30 days0 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