Anda di halaman 1dari 42

A 73 YEAR OLD MALE

WITH STEMI
ANTEROSEPTAL ,
ONSET > 24 HOURS
KILLIP I TIMI 7/14
BY:
Riany N. D. Tjowandi
SUPERVISOR:
dr. Pendrik Tendean, Sp. PD

PATIENT IDENTITY

RM number
:
Name
:
Sex
:
Age
:
Date administered :
23rd
2010

01.68.34
Mr. RY
Male
73 years old
November

HISTORY TAKING
Chief complaint : chest pain
The pain was located at the left side, described as a burn
sensation also with diaphoresis and was felt since
approximately 2 days before admitted to the hospital. The
pain radiated to the right side of the chest and was lasts for
more than 20 minutes. The pain was relieved with rest.
No shortness of breath, no history of SOB.
No cough
Nausea (+), no vomit
No epigastric pain
Defecation : Normal , micturation : Normal

HISTORY OF ILLNESS
A week ago, patient had same complaint
but the pain just lasted for < 15 minute ,
the upper limb felt numb and heavy.
History of DM is unknown.
History of hypertension (+) since 2003, not
treated.
History of smoking (+), since kid but
patient had stopped since 20 years ago.
History of cardiovascular disease in family
is unknown.

RISK FACTOR
MODIFIABLE

NON-MODIFIABLE

Smoking (+)
Dyslipidemia (-)
Hypertension
(+)
DM (-)
Obesity (-)

Age: 73 years
old
Gender: male
Personal history
of CAD (-)
Family history of
CVD (-)

PHYSICAL EXAMINATION
General Appearance
Moderate Illness/Well Nourished/
conscious
Vital Sign
BP : 160 / 100 mmHg
P : 118 bpm, regular
RR : 20 x/min, thoracoabdominal
T : 36.8 degree Celsius (axilla)

Head examination

Eyes
: no sign of anemia or icterus
Lip
: no sign of cyanosis
Neck : No mass, no tenderness,
JVP R+3 cmH2O

Chest Examination
Lung Examination
right

Inspection

: Symmetric left and

Palpation
: No mass, no
tenderness
Percussion
: Sonor
Auscultation
Breath sound
: Vesicular
Additional sound : No ronchi, no
wheezing

Cardiac Examination
Inspection
visible
Palpation
palpable
Percussion

: Ictus cordis not


: Ictus cordis not
:

Upper border : left ICS II


Lower border : left ICS VI
Right border
: right parasternalis line
Left border
: 2cm lateral to left
midclavicular line

Auscultation : regular of I/II Heart

Abdominal Examination
Inspection : Normal
Auscultation : Peristaltic sound (+),
normal
Palpation
: No mass, no
tenderness, liver
and spleen not
palpable
Percussion : tympani, no ascites

Extremities
warm.

: no oedema,

ELECTROCARDIOGRAPHY

INTERPRETATION
Sinus tachycardia, HR 125
Anteroseptal MCI
Anterolateral wall myocard ischemia

THORAX PHOTO ( Nov, 25th 2010 )


Bronchitis
Dilatation and atherosclerosis of
aorta

ECHOCARDIOGRAPHY

INTERPRETATION
Systolic and diastolic dysfunction ec
HHD
Mild AR
EF 33%

LABORATORY EXAMINATION
Biochemical blood test (NOV, 23rd 2010)
RBG
: 113 mg/dl
Ureum : 25 mg/dl
Creatinin : 1,1 mg/dl
SGOT : 72 mg/dl
SGPT : 18 mg/dl
Total Cholesterol : 182 mg/dl
LDL : 114 mg/dl
HDL : 41 mg/dl

Cardiac Enzyme (NOV, 23rd 2010)


CK
: 682
CKMB : 54 u/l
Troponin T : no reagen
Electrolyte (NOV, 23rd 2010)
Na
: 138 mmol/L
K
: 4 mmol/L
Cl
: 107 mmol/L

Routine Blood Test (Nov 23rd 2010)

WBC : 8,9.103/mm3
RBC : 4,81.103/mm3
Hb : 13,4 g/dl
PLT : 322. 103/mm3

Electrolyte ( Nov 26th 2010 )


Na
: 139 mmol/L
K
: 4,0 mmol/L
Cl : 106 mmol/L
Biochemical blood test ( Nov 26th 2010 )
Ureum : 22 mg/dl
Creatinine : 0,6 mg/dl
GOT : 30 u/L
GPT : 13 u/L

Cardiac Enzyme ( Nov 26th 2010 )


CK-MB

: 14 u/L

PT
: 11,2 control 0,97
APTT : 26,6 control 25,8

WORKING DIAGNOSIS

STEMI ANTEROSEPTAL, ONSET > 24


HOURS KILLIP I TIMI 7/14

MANAGEMENT

Bed rest
O2 3-4 L/min
Heart diet
IVFD NaCl 0,9% 16 drips/min
Cedocard 2mg/hr/sp
Lovanox 0,6cc/day/SC
Aspilet , loading dose 160 mg ( chewed )
Plavix 75 mg 0-1-0
Simvastatin 20 mg 0-0-1
Captopril 12,5 mg 1-0-1
Alprazolam 0,5 mg 0-0-1
Laxadin syr 0-0-1C

DI
S
C
U
S
SI
O
N

DEFINITION
Myocardial

infarction (MI) is the 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.
Evidence of ischemia.
Detection of arise and/or fall of cardiac
biomarkers.

Angina
Location - usually substernal, but radiated to
the neck, jaw, epigastrium, or left arm. Pain
above the mandible, below the epigastrium,
or localized to a small area over the left
lateral chest wall is rarely anginal.
Provocation

angina
is
generally
precipitated by exertion or emotional stress
( such as heavy meal, exertion, cold ), lasting 5 to 20
minutes and commonly relieved by rest or
sublingual nitroglycerin.

Angina
Quality

"squeezing,"

"griplike,"

"pressurelike," "suffocating" and "heavy; or


a "discomfort" but not "pain." Angina is
almost never sharp or stabbing, and usually
does

not

change

with

position

or

respiration.
Duration - anginal episode is typically
minutes in duration. Fleeting discomfort or
a dull ache lasting for hours is rarely

RISK FACTORS
Non- Modifiable
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

RISK FACTORS
Modifiable
High blood cholesterol
High blood pressure
Smoking
Diabetes
Obesity
Lack of physical activity

Major Risk Factors for Atherothrombotic


Events
Classical Risk Factors

Atherothrombotic History

Obesity
Family history of CVD
Diabetes
Lifestyle factors
Atrial fibrillation
Homocystinemia
Hyperlipidemia
Hypertension
Hypercoagulablestates
Gender
Age

Prior MI
Prior Stroke
Unstable angina
TIA
Stable angina
PAD

Risk Factors

Other Risk Factors


Elevated prothrombotic
factors: fibrinogen, CRP, PAI-1,
Elevated IMT
Genetic traits

Topol,Manual of Cardiovascular Medicine,2nd ed,2004

MI = Myocardial infarction
TIA = Transient ischemic event
PAD = Peripheral arterial disease
CRP = C-reactive protein
PAI-1 = Plasminogen activator inhibitor-1
IMT = Intima media thickness
CVD = Cardiovascular disease

Presentation of MCI
Longer (> 30 min)
Not decreased with nitrat
With other systemic symptoms

(nausea, vomiting, diaphoresis)


Old people, diabetes, women not
typical

Enzymatic Criteria for Diagnosis


of Myocardial Infarction
Serial increase (4-6 hours)
CK-MB > 25 U/L or > 5% total CK
activity.
Elevation of Troponin T best marker
(begin to raise in 3 hours).
CK-MB subform plus cardiac-specific
troponin is the best combination

Options for Transport of Patients With


STEMI and Initial Reperfusion Treatment
Hospital fibrinolysis:
Door-to-Needle
within 30 min.

Call 9-1-1
Call fastEMS on-scene

Onset of
symptoms
of STEMI

GOALS

9-1-1
EMS
Dispatch

Encourage 12-lead ECGs.


Consider prehospital
fibrinolytic if capable and EMSto-needle within 30 min.

5
8
EMS Transport
min. min.
Patient EMS
Prehospital
fibrinolysis
EMS-to-needle
within 30 min.
Golden Hour = first 60 min.

Not PCI
capable
InterHospital
Transfer

EMS
Triage
Plan

PCI
capable

EMS transport
EMS-to-balloon within 90
min.
Patient self-transport
Hospital door-to-balloon
within 90 min.
Total ischemic time: within 120 min.

Antman EM, et al. J Am Coll Cardiol 2008. Published ahead of print on December ;
ACC/AHA STEMI Guideline 2009

Initial Treatment
1. Oxygen (2-4L/mnt)
2. Nitrat (sublingual or iv) caution if BP < 90mmHg
3. Anti platelet co-therapy :
- Aspirin 160-325mg (soluble or chewable) or iv
dose and follow by
- Clopidogrel 300-600mg, preferable 600mg (if age
< 75 yo ; if age > 75 yo only give 75mg)
4. Morphine 4-8mg iv or sc with additional doses 2mg at 5-15
minutes intervals (depending on pain severity)
tranquilizer in very anxious patient
2007 ACC/AHA Guideline UAP/NSTEMI
2008 ESC Guideline STEMI
2009 ACC/AHA Guideline STEMI

PROGNOSIS
KILLIP CLASSIFICATION
Class

Description

Mortality Rate
(%)

I
II

No clinical signs of heart failure


Rales or crackles in the lungs, an
S3, and elevated jugular venous
pressure

6
17

III
IV

Acute pulmonary edema


Cardiogenic shock or
hypotension (systolic BP < 90
mmHg), and evidence of
peripheral vasoconstriction

30 - 40
60 80

Secondary Prevention
Ask, advise, assess, and assist
patients to stop smoking
Aspirin 80-100mg daily and
Clopidogrel 75 mg daily
Statin goal:
LDL-C < 100 mg/dL

Daily physical activity 30 min 3


to 4 days/week

37

Secondary Prevention
Blood Pressure Control: <140/90 mmHg or
<130/80 mmHg if patient have diabetes or
chronic kidney disease.
Weight Management:
Goals: BMI 18.5 - 24.9 kg/m2 and
Waist circumference in men <40
inch women <35 inch
Diabetes Management:
HbA1c less than 7%.
Stress Reduction

THANK YOU

Increased serial cardiac marker

Troponin T/Troponin I
CKMB

41

Anticoagulants
I IIa IIb III

C
I IIa IIb III

Patients undergoing reperfusion with


fibrinolytics should receive anticoagulant
therapy for a minimum of 48 hours (Level of
Evidence: C) and preferably for the duration
of the index hospitalization, up to 8 days
(regimens other than unfractionated heparin
[UFH] are recommended if anticoagulant
therapy is given for more than 48 hours
because of the risk of heparin-induced
thrombocytopenia with prolonged UFH
treatment). (Level of Evidence: A)
Anticoagulant regimens with established
efficacy include:
UFH (LOE: C)
Enoxaparin (LOE:A)
42 2008
Modified from ESC STEMI Guideline
Fondaparinux
(LOE:B)
and ACC/AHA Guideline STEMI 2009

Anda mungkin juga menyukai