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
Palpation
: No mass, no
tenderness
Percussion
: Sonor
Auscultation
Breath sound
: Vesicular
Additional sound : No ronchi, no
wheezing
Cardiac Examination
Inspection
visible
Palpation
palpable
Percussion
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
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
WBC : 8,9.103/mm3
RBC : 4,81.103/mm3
Hb : 13,4 g/dl
PLT : 322. 103/mm3
: 14 u/L
PT
: 11,2 control 0,97
APTT : 26,6 control 25,8
WORKING DIAGNOSIS
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
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,"
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
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
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
Call 9-1-1
Call fastEMS on-scene
Onset of
symptoms
of STEMI
GOALS
9-1-1
EMS
Dispatch
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
6
17
III
IV
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
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
Troponin T/Troponin I
CKMB
41
Anticoagulants
I IIa IIb III
C
I IIa IIb III