STEMI Inferior Wall Onset 3 Hours

KILLIP I
By:
RAHMAWATI
(C111 07 200)

Supervisor:
dr. JUZNY ALKATIRI, Sp.PD,Sp.JP, FIHA, FINASIM

CARDIOLOGY DEPARTMENT
FACULTY OF MEDICINE HASANUDDIN UNIVERSITY
WAHIDIN SUDIROHUSODO HOSPITAL
2012
PATIENT’S IDENTITY
Name : Mr. B
Gender : Male
Age : 58 years old
Address : BTN minasaupa No.14
Registration no : 551033
Date of Admission : May 24, 2012
HISTORY TAKING
 Chief Complain : Left Chest Pain

 Present illness history:

Chest pain was felt since 1 day before
admitted to the hospital and became more
severe 3 hours ago. This pain was
described as a pressure sensation and
also feel like crushed. Pain was felt on the
left side of chest and spread to the neck,
shoulder and his left arm.
• Cold Sweat (+) while chest pain occurred
• Palpitation (+)
• Cough (-) ,mucus (-)
• Nausea (-), vomiting (-) , epigastric pain (-)
• Dizziness (-), headache (-) .
• Urination = normal
• Defecation = normal
PREVIOUS ILLNESS HISTORY

• History of hypertension (-)

• History of Diabetes mellitus (+) since 3
year ago, uncontrolled treatment
• History of heart disease (-)
• History of smoking (+) ± 1 pc/day for ± 10
years
RISK FACTOR
Modified Risk Factor
• Diabetes Mellitus since 3 year ago,uncontrolled treatment
• Smoking ± 1 pc/day for ± 10 years

Non-modified risk factor:

• Gender : man
• Age > 56 years old
PHYSICAL EXAMINATION
• General appearance = moderate illness/well-
nourished/composmentis

• Vital Sign
BP : 110/70 mmHg RR : 22x/min
HR : 100x/min T : 36.8oC(afebris)

• Head : Anemi (-) , icterus (-)

• Neck : JVP + 1 cm H20
CONT…

• Chest Examination
I : symmetric R=L, normochest
P : mass (-), tenderness (-), VF R=L
P : sonor
A : breath sound : bronchovesicular
additional sound : ronchi -/-
wheezing -/-
• Cor
I : ictus cordis unseen
P : ictus cordis unpalpable
P : dull, normal heart size
A : HS I/II pure regular, murmur(-)
CONT…

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

• Extremitas : edem -/-

ECG FINDINGS
ECG Interpretation

 Sinus Rhythm
 QRS Rate : 100 x/i
 P Wave : 0.08 ’
 PR interval : 0.20 ’
 QRS complex : 0.08 ’
 Axis : normoaxis
 ST elevated at II, III, AVF
  Atrioventricular
Echocardiogram dimention are normal
LVH (+)
 Decrease of LV
contractility, EF 36 %
 Hypokinetic global
 Valves are in normal
condition
 E/A >1 (pseudonormal)

Conclusion :
1. Systolic & diastolic LV
dysfunction, EF 36%
2. LVH (+)
3. Hypokinetic global
 Laboratorium Finding

Complete blood count

Parameter Result

WBC 24.58 x 10 3 / ul

RBC 5.67 x 10 6 / ul
Hb 16.2 g/dl
HCT 45.4 %
PLT 222 x 10 3 / ul

Conclusion : Leukosytosis
Chemistry blood
Parameter Result

GOT 505 u/L

GPT 305 u/L
Ureum 99 mg/dl
Kreatinin 1,8 mg/dl
GDP 312 mg/dl
HBA1C 8,4 %
Kolesterol total 222 mg/dl
trigliserida 435 mg/dl
CK 2706 u/l
CK-CKMB 189 u/l
Troponin T 1,7
Electrolite

Parameter Result

Natrium 128 mmol/L

Calium 6,2 mmol/L
Clorida 91 mmol/L

Conclution : Imbalanced electrolit

DIAGNOSIS

ST Elevation Miocard Infarction (STEMI)

Inferior Wall Onset 3 Hours KILLIP I
MANAGEMENT

• Bed Rest
• O2 – 6-8 lpm
• IVFD NaCl 0.9% 10 tpm
• Aspilet 80mg 1-0-0
• Plavix 75mg 0-1-0
• cedocard 0,5 mg/hour/sp
• Streptase 1,5 juta IU/iv/gorant
• Fasorbid 5mg/kp
• Simvastatin 20mg 0-0-1
• Alprazolam 0.5mg 0-0-1
• Laxadin syr 0-0-II
• Petidine 2,5 mg/iv/kp
ADVISE

• Coronary Angiography
Acute Myocardial Infarction
 Introduction

• Acute myocardial infarction (AMI) is

an irreversible necrosis of heart muscle
due to prolonged ischemia, which is
suddenly happened.

• Imbalance in oxygen supply and

demand, which is most often caused by
plaque rupture with thrombus
formation in a coronary vessel,
resulting in an acute reduction of blood
supply to a portion of the myocardium.
Risk Factor
Modifiable Non-modifiable
 Smoking  Gender and age:
 Hypertension - male after age 45 y.o
 Obesity - ♀ after age 55 y.o
 Diabetes Mellitus
 Dyslipidemia  Family History
 Low HDL < 40 in first degree
 Elevated LDL / TG relative > 55 y.o for
male/ 65 y.o for ♀
WHO Diagnostic Criteria

1. Clinical history of ischaemic type chest pain lasting >20

minutes
2. Changes in serial ECG tracings
3. Rise of serum cardiac biomarkers such as creatinine
kinase-MB fraction and troponin-T
Clinical Features
• 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
ECG in AMI
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
 How to Diagnosis

Signs of myocardial ischemia

ECG
Yes
Acute Myocardial Infarction
ST segmen elevation ? (STEMI)

No Lab
Yes NSTEMI
↑ Biochemical cardiac markers ? ( Non ST-Elevation
Myocardial Infarction )

No

Unstable Angina
Management
Fixing the chest pain and fearness
• Bed rest
• Diet
• O2 2-4 lpm
• Nitrat sublingual/oral/IV
• Antiplatelet : aspirin and clopidogrel
• Morfin/petidine
• Diazepam 2-5mg/8 hour
Stabilizing the hemodynamic ( blood pressure and pheripheral pulse control)
• β-blocker
• Calcium chanel blocker (CCB)
• ACE-Inhibitor
Reperfusion of the myocard
• Thrombolitik
Management
Treating Chest Pain and Stress:
• O2 2-4 LPM
• Isosorbid dinitrate 5 mg SL
• Low dose aspirin (Aspilet) 80 mg loading 2 tab 160mg
• Clopidogrel 75 mg, loading 4 tab 300 mg
• Diazepam 2-5 mg / 8 hours
Hemodinamic Stabilization
• Fasting first 8 hours after attack, soft food
• Laxadyn
• Bed rest until 24 hours free from angina
• Cardioselective Beta Blocker  Bisoprolol
(do not use if hypotension or Bradicardia)
• Ace Inhibitor
Myocardial Reperfusion
• Thrombolytic  effective with onset < 12 hours
• Streptokinase (streptase) 1,5 million unit soluted in 100 ml Nacl O,9%
• Anti coagulant  low molecular weight heparin
• Fondaparinux (Arixtra)

Plaque Stabilization  Simvastatin

TIMI PROGNOSIS IN STEMI

Risk Factor Score

Age > 65 years old 2
Age > 75 years old 3
History of
angina/hypertension/DM 1/1/1
Systolic BP <100 3
Heart rate > 100 2
Killip II-IV 2
Weight > 67kg 1
Anterior MI or LBBB 1
Delay treatment >4hours 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%
9-16 35.9%
 Prognosis  Killip Classification

Class Description Mortality Rate (%)

I no clinical signs of heart failure 6
II rales or crackles in the lungs, an S3, 17
and elevated jugular venous pressure

III acute pulmonary edema 30 - 40

IV cardiogenic shock or hypotension 60 – 80
(systolic BP < 90 mmHg), and evidence
of peripheral vasoconstriction