By: Andi Fauziah Armayani (C111 07 070) Supervisor: dr. Khalid Saleh, Sp.

PD- KKV, FINASIM

CARDIOLOGY DEPARTMENT FACULTY OF MEDICINE HASANUDDIN UNIVERSITY WAHIDIN SUDIROHUSODO HOSPITAL 2013

Name Gender Age Registration no Date of Admission

: : : : :

Mr. K Male June 16, 1986 601336 March 28, 2013

Chief Complain :
Chest Pain

Present illness history:

Chest pain was felt since 4 hours before admitted to the hospital. This pain was felt continue and described as a squeezing sensation. Pain was felt on the left side of chest and radiated to the neck, shoulder, his left arm and the back.

Cold Sweat (+) while chest pain occurred Palpitation (+) Nausea (+), vomiting (-) , epigastric pain (-) Short of breathness (-), history of short of breathness (-) Cough (-) ,mucus (-) Dizziness (-), headache (-) . Urination = normal Defecation = normal

 History

of hypertension (-) History of Diabetes mellitus (-) History of heart disease (-) History of smoking (+) 2 packs/day since 10 years ago

Modified Risk Factor

Smoking 2 packs/day

Non-modified risk factor:

Gender : man

General appearance Vital Sign Head Neck

moderate illness/wellnourished/conscious
BP : 120/80 mmHg P : 72 x/min R : 20 x/min T :36.8oC

Anemi (-) , icterus (-)

JVP R - 2 cm H20

Chest Examination

I : symmetric R=L, normochest P : mass (-), tenderness (-), VF R=L P : sonor A : breath sound :bronchovesicular additional sound : ronchi -/- , wh -/-

Cor

I : ictus cordis unseen P : ictus cordis unpalpable P : dull, left heart border left midclavicular line ICS V. A : HS I/II pure regular, murmur(-)

Abdomen :
Inspection : flat and correspond with breathing movement Auscultation : peristaltic sound (+) , normal Palpation : liver and spleen unpalpable Percussion : tympani, ascites (-)

Extremitas :
edem -/-

ECG Interpretation
Sinus Rhythm

Heart Rate :60 x/I

P Wave : 0.06 PR interval : 0.12

QRS complex

:0.08 Axis : normoaxis ST-elevated : V1V6, L1 & aVL

 Sinus Rhythm, heart rate :60 x/minute, normoaxis,

ST elevated at V1, V2, V3, V4, V5, V6 + L1 and AVL

Complete blood count

Test WBC RBC HGB HCT PLT Result 21.1 x 103/ul 5.00 x 106/l 14.8 gr/dl 46.4 % 283 x 103 /l Normal value 4.0 10.0 x 103 4.0 6.0 x 106 12 16 37 48 150 400 x 103

Blood Chemistry
Test GDS Ureum Creatinine SGOT SGPT Total Chol HDL Chol LDL Chol TG Cardiac Enzymes Test CK CK-MB Result 419 U/L 16 U/L Normal value <167 <25 Result 112 mg/dl 25 mg/dl 1.0 mgr/dl 24 u/l 15 u/l 129 mg/dl 37 mg/dl 54 mg/dl 91 mg/dl Normal value <140 10 50 < 1.3 <38 <41 <200 > 55 < 130 <200

Troponin-T

>2.0

Negative

Electrolyte
Test Result 145 mmol/l 3.9 mmol/l 109 mmol/l Normal value

Na
K Cl

136-145
3.5-5.1 97-111

ST Elevation Myocardial Infarction (STEMI) Extensive Anterior 4 Hours KILLIP I

O2 2-4 lpm IVFD NaCl 0,9% 500cc/12h Anti platelet Aspilet 80mg 1x1

Anti

platelet Clopidogrel 1 x 75mg Anti Thrombolytic Streptokinase 1.5 million IU in 60 minutes Anti coagulant Fondaparinux Sodium 2.5 mg/24 h/ S ACE Inhibitor Captopril 12.5 mg -0- Statin simvastatin 20 mg 0-0-1 Lactulosa Laxadyn syr Benzodiazepine Alprazolam 0.5 mg 0-0-1

 Echocardiography
Angiography

PATHOPHYSIOLOGY
Occurs when

coronary blood flow decreases abruptly after a thrombotic occlusion of a coronary artery previously affected by atherosclerosis. In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates.

CLASSIFICATION

ACS describe a group of conditions resulting from acute myocardial ischemia (insufficient blood flow to heart muscle) ranging from unstable angina to myocardial infarction.

Modifiable Smoking Hypertension Obesity Diabetes Mellitus Dyslipidemia Low HDL < 40 Elevated LDL / TG

Non-modifiable Gender and age: male after age 45 y.o woman after age 55 y.o Family History in first degree relative > 55 y.o for male/ 65 y.o for woman

Clinical history of ischaemic type chest pain lasting >20 minutes

Changes in serial ECG tracings

Rise of serum cardiac biomarkers such as creatinine kinase-MB fraction and troponin-T

Substernal chest pain / chest discomfort radiated to the left arm, shoulder, neck, jaw. Penetrated to the back. The chest discomfort may also be described as a dull pain ,pressure, squeezing or crushing sensation or burning sensation Duration more than 20 minutes. more intense and persistent. Not fully relieved by rest or nitroglycerine Often accompanied by systemic symptoms: nausea, vomiting, SOB, palpitation, fatigue, cold sweat, light headness

Hyperacute Phase Non Specific ST-Elevation T taller and wider Complete Evolution Specific ST-Elevation T inverted Q Phatologic Old Infarct

Q- Phatologic ST segmen isoelectric T normal or inverted

Signs of myocardial ischemia

ECG
Yes

ST segmen elevation ?
No

Acute Myocardial Infarction (STEMI)

Lab
Yes
NSTEMI ( Non ST-Elevation Myocardial Infarction )

Biochemical cardiac markers ?

No

Unstable Angina

Fixing the chest pain and fearness

Bed rest Heart Diet O2 Nitrat sublingual/oral/IV Antiplatelet : aspirin and clopidogrel Morfin/petidine Diazepam

Stabilizing the hemodynamic ( blood pressure and pheripheral pulse control

-blocker Calcium chanel blocker (CCB) ACE-Inhibitor

Reperfusion of the myocard

Risk Factor Age > 65 years old Age > 75 years old History of angina/hypertension/DM Systolic BP <100 Heart rate > 100 Killip II-IV Weight > 67kg Anterior MI or LBBB Delay treatment >4hours

Score 2 3
1/1/1 3 2

2 1 1 1

Total Score 0 1 2 3 4 5 6 7 8 9-16

Risk of Death in 30 days 0.8% 1.6% 2.2% 4.4% 7.3% 12.4% 16.1% 23.4% 26.8% 35.9%

Class Description I no clinical signs of heart failure

Mortality Rate (%) 6

II

III IV

rales or crackles in the lungs, an S3, and elevated jugular venous pressure acute pulmonary edema
cardiogenic shock or hypotension (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction

17

30 - 40 60 80

Thank you