Stemi 3u5e1e

Indra Christianto Adaptasi L.N.

ST Elevation Myocardial Infarction : onset 13 Hours, KILLIP I

PATIENT’S IDENTITY Name Age Gender Medical Record No Address Date of ission Room

: Mr. A.G : 31 y.o : Male : 819274 : Bantaeng : Okt 16th 2017 : CVCU RSWS

ANAMNESIS Chief complaint : Chest Pain Present history : Chest pain was felt about 13 hours before hospital ission. It was felt suddenly when the patient was resting. Patient complained about a burning sensation in the middle of the chest. The pain did not spread to the arms, shoulder, nor jaw area, also did not penetrate to the back area. The duration of the pain was >30 minutes. And was also not relieved by rest or position change. The patient then was itted to RSUD in Bantaeng, and was given half tablet of methyl prednisolone. The pain diminished but was not completely vanished. After the abnormal ECG, patient received treatment (wasn’t sure what was the drugs) and then referenced to our hospital. There was no heart palpitation, no dyspnea, no cough, no nausea or vomiting. Defecate and urination was normal

PAST HISTORY There was no history of hypertension. History of diabetes mellitus was also denied, there was no history of the same complain before. There was no other disease.

FAMILY HISTORY

-------------------------------There was no family member with the same complaints

Could be modified: ✘Hypertenstion(-)

✘Diabetes mellitus (-) ✘Dyslipidemia (-) ✘Obesity (-) ✘Smoking(+) 1 pack a day ✘History of heart disease (-)

Cant be Modified : • • •

Sex : male Age : <50 years Family history of heart disease (-)

PHYSICAL General State EXAMINATION Interpretation

: Moderate Illness

Level of Consciousness

: Compos mentis

Nutrition

: Sufficient

Vital sign BP : 120/70 mmHG

˚C

R: 22x/min

HR: 80x/min

T:36.5

Head and Neck o Anemia

: Negative

o Jaundice

: Negative

o Cyanosis

: Negative

o JVP R + 2 cmH20

Thorax o

Inspection : The right and left are symmetrical, No injury,

No Masses o

Palpation : No tenderness, No crepitus

o

Percussion : Sonance

o

Auscultation : Vesicular, No Rhonchi and No Wheezing

Heart o

Inspection : Ictus cordis was not appeared

o

Palpation : Thrill was not palpable, No Tenderness

o

Percussion : Normal Heart Border

o

Auscultation : S1 S2 regular, no murmur

Abdomen Inspection : Due to the breathing movement, no enlargement Palpation : No tenderness, no enlargement of liver and spleen Percussion : Tympani Auscultation : Peristaltic is normal

Extremity o o

Inspection : No edema Palpation : Warm extrimities

ELECTROCARDIOGRAM Interpretation: • • • •

Sinus rhythm HR 75x/min Normoaxis ST elevation Myocardial infaction (STEMI) anteroseptal wall

Test

L A B R E S U L T

Result

Normal Value

WBC

20.16

4.00 – 10.0

RBC

5.68

4.000 – 6.0

HGB

16.7

12.0 – 16.0

HCT

47.3

37.0 – 48.0

PLT

274

150 – 400

Ureum

23

10-50

Kreatinin

0.77

<1,3

SGOT

206

<41

SGPT

52

<38

Na

137

136-145

K

4.7

3,5-5,1

Cl

100

97-111

GDS

214

140

LAB RESULT Test

Result

Normal Value

3153.75

< 190

CK-MB

308

< 25

Troponin I

7.71

<0.01

CK

ECHOCARDIOGRAM Interpretation : •

Systolic function of Left Ventricle is decreased. Ejection fraction 46%

•

Diastolic dysfunction grade 2

•

Segmental hypokinetic

DIAGNOSIS ST Elevation Myocardial Infarction (STEMI) : Onset 13 hours, KILLIP I

therapy ✘Oxygen 4 Litre/min binasal ✘IVFD NaCl 0,9 500 cc/ 24 hours/ IV ✘Clopidogrel 75mg/24 hours/ oral ✘Aspilet

80mg /24 hours/ oral

✘Farsorbid 1mg/hours/syringepump ✘Atorvastatin 40mg/24hours/oral ✘Ramipril 2.5mg/24hours/oral

✘Bisoprolol 2.5mg/24hours/oral ✘Arixtra 2.5 mg/24 hours / subcutaneous (already received in

DISCUSSION

What is Myocardial Infarction? ✘ Commonly known as a heart attack, is the irreversible necrosis of heart muscle secondary to prolonged ischemia. ✘ Results from an imbalance in oxygen supply and demand, caused by plaque rupture with thrombus formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion

Risk Factor

1. Old People : Individuals aged older than 45 years have an eight times greater risk for AMI. 2. Male Sex 3. Hypertension 4. Dyslipidemia 5. Diabetes 6. Smoking 7. Obesity and physical inactivity 8. Acute and prolong intake of alcohol 9. Family history

Coronary Arterial Occlusion. ✘Rupture of high-risk atheromatous plaque in the coronary arteries is a primary causative factor in the development of AMI. ✘When exposed to subendothelial collagen and necrotic plaque contents, platelets adhere, become activated, release their granule contents, and aggregate to form microthrombi. ✘Vasospasm is stimulated by mediators released from platelets ✘Tissue factor activates the coagulation pathway, adding to the bulk of the thrombus.

Myocardial Response. ✘Coronary arterial obstruction diminishes blood flow to a region of myocardium causing ischemia, rapid myocardial dysfunction, and eventually—with prolonged vascular compromise — myocyte death ✘The anatomic region supplied by that artery is referred to as the area at risk.

✘The

earliest

detectable

feature

of

myocyte

necrosis is the disruption of the integrity of the sarcolemmal

membrane,

allowing

intracellular

macromolecules to leak out of necrotic cells into

the cardiac interstitium and ultimately into the microvasculature and lymphatics. ✘Intracellular

myocardial

proteins

into

the

circulation forms the basis for blood tests that

CLASSIFICATION o Anatomic : 1. Transmural infarction- Transmural infarcts extend through the whole thickness of the heart muscle and are usually a result of complete occlusion of the area's blood supply 2. Subendocardial (nontransmural) infarction -

involves a small area in the subendocardial wall of the left ventricle, ventricular septum,

o Diagnostic

1. ST Elevations Myocardial Infarction (STEMI)

2. Non-ST Elevations Myocardial Infarction (NSTEMI)

Signs and Symptoms 1. Chest Pain • • • • •

Most common symptom Described as a sensation of tightness, pressure, or squeezing. Not relieved by rest, position change or nitrate istration. Pain radiates most often to the left arm, but may also radiate to the lower jaw, neck, right arm, back, and upper abdomen, where it may mimic heartburn. Levine's sign, in which a person localizes the chest pain by clenching their fists over their sternum SILENT AMI - 20-30% subjects don’t have chest pain, common in patients with diabetes mellitus, hypertension, & in elderly patients.

2. Nausea and Vomiting 3. Shortness of Breath •

the damage to the heart limits the output of the left ventricle, causing left ventricular failure and consequent pulmonary edema.

4. Diaphoresis (an excessive form of sweating), 5. Light-headedness 6. Palpitations 7. Loss of consciousness •

Due to inadequate blood flow to the brain and

Diagnosis According to the WHO criteria as revised in 2000, a cardiac troponin rise accompanied by either typical symptoms, pathological Q waves, ST elevation or depression or coronary intervention are diagnostic of MI.

Serum Cardiac Biomarkers The combination of CK-MB and troponin testing have higher sensitivity and is used for the purpose of "ruling out" myocardial infarction.

ECG Changes • ST segment elevation, followed by T wave inversion and Q waves, are associated with transmural infarction. • ST segment depression and T wave inversion are associated with subendocardial infarction.

Management o ONACoM 1. Oxygen 2. Nitroglycerin 3. Aspirin 4. Clopidogrel 5. Morphine (if the pain is not relieved by nitrogycerin)

o Other early hospital therapy

• Anticoagulant  Low Molecular Weight Heparin (LMWH)

• Fibrinolytics

• ACE-Inhibitor • Beta-Blockers (cardiosensitive)

• Statins

Revascularisation Procedure ✘Percutneous Coronary Intervention / Angioplasty (PCI). ✘Coronary Artery By – (CABG).

✘ Transmyocardial Laser Revascularization

PREVENTION 1. Lifestyle Modification Stop smoking, reduce alcohol intake, excercise 2. Diet Diets rich in soluble fiber, vegetables, fruits, and whole grains, and low in saturated fat/trans fat and cholesterol should be encouraged. 3. Management and control of comorbid diseases Manage hypertension, and DM 4. Patient education Patients, their family , and the community should be educated properly, especially on how to detect and respond to an episode of AMI

complications ✘Arrhythmia ✘Hypotension ✘CHF ✘Cardiogenic Shock

Prognosis KILLIP Classification Class

Definition

Patient Proportion

Mortality(%)

I

Absent cracles and S3

40-50%

6

30-40%

17

10-15%

30-40

5-10%

60-80

II

Cracles in the lower half of the lung

fields ans possible s3 Cracles more than halfway up the

III

lung fields and frequent pulmonary edema

IV

Cardiogenic shock

THANKS!

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