By :Mohd Farhannuddin B. Saidin

Supervisor :Dr. Khalid Saleh,SpPD

Patient IdentityName: Mrs. PAge : 80 years oldAddress: Jl. Patedong LuwuMedical record: 559250Admitted: July 12th , 2012

History TakingChief complaint: Shortness of breathHistory taking: Felt since 1 month ago and worsen 10 days before admitted to the hospital. The symptom occurred during activity and not influenced by weather. Patient always sleep using 2-3 pillow and always woke up at night due to shortness of breath. Shortness of breath was accompanied by chest pain. Patient felt weighted on her left chest for 30 minutes, pain penetrates to the back of the body and shoulder. The pain did not improved by rest.Sweating (+) , Dyspnea (+), Nausea (+), Vomiting (+),Epigastric pain (+), Cough(+), Defecation & urination is normal

History of illnessHypertension (+) since 10 years ago, do not controlled regularly. Diabetes mellitus (-) History of dyslipidemia (-)History of personal cardiovascular disease (-).Family history of heart disease (+)

Risk factor

Physical ExaminationGeneral Status : Moderate-illness/normal BW/consciousVital Sign :Blood Pressure: 130/90 mmHgPulse : 112 bpm, regularRespiratory rate : 28 tpm, abdominothoracalBody temperature : 36,7 C

Head ExaminationEyes: anemic -/-, icterus -/-Lip : cyanosis (-)Neck: lymphadenopathy (-), JVP R +2 cmH2OChest ExaminationInspection : symmetric R=L, normochestPalpation : mass (-), tenderness (-), VF R=LPercussion : sonorAuscultation : breath sound :bronchovesicular additional sound : ronchi - /- + /+ +/+ wheezing -/-

Cardiac ExaminationInspection: IC wasnt visiblePalpation : IC wasnt palpablePercussion: normal heart size- Upper border: left 2nd ICS- Lower border: left 5th ICS - Right border: right parasternalis line- Left border: left medioclavicular lineAuscultation : Regular of I/II heart sound, murmur (-)

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Abdominal Examination - Inspection : flat and following breath movement- Auscultation : peristaltic sound (+) , normal- Palpation : liver and spleen unpalpable- Percussion : tympani, ascites (-)Extremities - Oedema : pretibial -/- dorsum pedis -/-

LABORATORY FINDINGS

Electrolyte (July, 12h 2012) Sodium : 132 mmol/L Potassium : 8.3 mmol/L Chloride : 99 mmol/L

Cardiac Enzyme (July, 12th 2012) CK : 164 U/L CK-MB : 12 U/L Trop. T : >2.0

ECG

InterpretationSinus thacycardiaHR 107 x/minuteNormal AxisST elevation in V1-V4

ECHOCARDIOGRAPHY

EchocardiographyConclusion Decrease LV contractility function ,EF 38 %LA Dilatation LVH (+)Global hypokineticMR trivialDiastolic dysfunctionPleural efusion

WORKING DIAGNOSISSTEMI Anteroseptal Wall onset >24 hours Killip III

MANAGEMENTBed restO2 2-4 L/minIVFD NC 500cc/24h/ivDiuretic : Lasix 2amp/12hrs/ivNitrate :Cedocard 1mg/hrs/spAnti-platelet aggregation : Aspilet loading 80 mg (2 tab), maintenance 1-0-0Clopidogrel loading 75mg (4tab), maintenance 0-1-0Anti-coagulant : Arixtra 2,5mg/24hrs/SCAnti- hypertension : Captopril 12,5 mg 1-1-1 Cholesterol: Simvastatin 20mg (0-0-1)Anti-anxiety : Alprazolam 0.5 mg (0-0-1)Laxative: Laxadyne syr 0-0-2C

Acute Myocardial Infarction

DEFINITION Myocardial infarction (MI) is rapid development of myocardial necrosis caused by imbalance oxygen supply and demand of the myocardium.

It results from plaque rupture with thrombus formation in a coronary vessels, resulting in an acute reduction of blood supply to a part of the myocardium.

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

RISK FACTORSModifiable:HypertensionDiabetes MellitusSmokingHypercholesterolemiaLow HDL cholesterol( 200mg/dl)ObesityNon-modifiable:Gender: maleAge (Men > 45 years; women> 55 years)Personal history of Coronary Artery DiseaseFamily history of premature Coronary Artery Disease (CAD in male 1st-degree relative < 65 years)

CLINICAL FEATURESDeep and visceral chest pain > 20 minutes, similar to discomfort of angina pectoris but commonly occurs at rest, more severe, and lasts longer.2Feels like heavy, squeezing, crushing, burning sensation.2Involves the central portion of chest and/or the epigastrium, radiates to the arm, abdomen, back, lower jaw, and neck.2It is often accompanied by weakness, sweating, nausea, vomiting, anxiety.2Not relieved by rest or nitrat.1

WHO Diagnostic criteria of MI Clinical history of ischaemic type chest pain lasting >20 minutesChanges in serial ECG tracings (ST-segment elevation or new onset LBBB)Rise of serum cardiac biomarkers: CKMB, Troponin T/I

Management Fixing the chest pain and fearness1Bed restDietO2 2-4 lpm via nasal prongs or face maskSublingual/oral/IV nitroglycerineAntiplatelet: aspirin and clopidogrelMorfin/petidineDiazepam 2-5mg/8 hour Stabilizing the hemodynamic (blood pressure and peripheral pulse control)1-blockerCalcium channel blocker (CCB)ACE-Inhibitor Reperfusion of the myocard1Thrombolytic

Surgical revascularizationPTCA (percutaneous transluminal coronary angioplasty)CABG (coronary artery bypass grafting)

RISK COMPLICATION of MIBased on KILLIP classification:

Classification DescriptionKILLIP INo crackles, no 3rd heart soundKILLIP II Crackles in 50% of lung field, lung edemaKILLIP IVCardiogenic shock

COMPLICATION of MICongestive heart failureMyocardial ruptureArrhythmiaPericarditisCardiogenic shock

TIMI Prognosis in MI

Risk Factor ScoreAge > 65 years oldAge > 75 years old23History of angina/hypertension/ DM1Systolic BP 1002Killip II-IV2Weight > 67kg1Anterior MI or LBBB1Delay treatment >4hours1

RISK FACTORS

Total Score Risk of Death in 30 days00.8%11.6%22.2%34.4%47.3%512.4%616.1%723.4%826.8%9-1435.9%

THANK YOU

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