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STEMI INFEROPOSTERIOR ET RIGHT VENTRICULAR ONSET 2 HOURS KILLIP I
Presented by:Henry Liemer Wijaya
Supervisor :dr. Khalid Saleh, Sp.PD-KKV, FINASIM
Department of Cardiology and Vascular MedicineMedical Faculty of Hasanuddin University
Makassar2013
PATIENT IDENTITY
Medical Record : 622664 Name : Mr. R Gender : Male Age : 31 years old Address : Maros Date of admission : 13 August 2013
HISTORY TAKING Chief complaint:
Chest Pain
History of Present Illness:
The chest pain began since 2 hours ago before he was admitted to Wahidin Sudirohusodo Hospital. The sensation of chest pain suddenly appeared when the patient was resting at home. The pain is described like dull heavy feeling on the left chest, radiated to his back, shoulder and left hand. The chest pain was accompanied with cold sweat and tightness sensation. The patient felt nausea and not vomiting. The chest pain felt continuously more than 20 minutes duration, and not relieved by rest.
The patient felt breathlessness while having chest pain, and it was accompanied by palpitation and cold sweat. He never wakes up from her sleep in the night because of breathlessness. He could sleep with 1 pillow only. There was no cought and fever. No history of epigastric pain. Urination and defecation were normal.
HISTORY TAKING History of Past Illness:
History of chest pain before (-)
History of smoking ( + ) 2 packs/day
History of hypertension : denied
History of drinking alcohol (-)
No history of heart disease
No family history of heart disease
History of diabetes mellitus : denied
No history of dyslipidemia
No history of asthma
No history of epigastric pain
RISK FACTOR
Gender: Male
NonModifiable
Smoking (+)Obesity (+)
Modifiable
PHYSICAL EXAMINATION
General StatusModerate illness/obesity 1/composmentis
Vital Signs BP : 130/80 mmHg HR : 70 bpm, regular RR : 22 tpm T : 36.7˚C BW : 82 kg H :170 cm BMI : 28,3 kg/m2
PHYSICAL EXAMINATION Head Examination
Eyes : Anemic -/-, Icterus -/- Lips : Cyanosis (-) Neck : Lymphadenopathy (-), JVP R+1 cmH2O
Thorax Examination Insp. : Symmetrical R=L, normochest Palp. : Mass (-), tenderness (-), VF R=L Perc. : Sonor Ausc. : Vesicular
Ronchi -/-, Wheezing -/-
PHYSICAL EXAMINATION
Cardiac Examination Insp. : IC wasn’t visible Palp. : IC wasn’t palpable Perc. : Dull, normal heart size
Right border : Right parasternalis line Left border : Left medioclavicularis
line Ausc. : Pure regular of I/II heart sound, murmur
(-)
PHYSICAL EXAMINATION
Abdominal Examination Insp. : Flat and following breath movement Ausc. : Peristaltic sound (+), normal Palp. : Liver and spleen is unpalpable Perc. : Tympani (+), ascites (-)
Extremities Oedema : Pretibial -/-, Dorsum pedis -/-
ELECTROCARDIOGRAPHY
ELECTROCARDIOGRAPHY
ELECTROCARDIOGRAPHY Interpretation:
Rhythm : Sinus QRS-Rate : HR 75 bpm, reguler P-Wave : 0.08 sec PR-Interval : 0.16 sec QRS Complex : 0.08 sec Axis : 120˚ ST-Segment : ST-elevation
on lead II, III, aVF, V3R, V4R, V5R, V6R, V8, and V9.
T-Wave : Normal
Conclusion: Sinus Rhythm, HR 75 bpm, RAD, inferoposterior and right ventricular acute myocardial infarction.
CHEST X-RAY
14 Augusts 2013
Normal pulmonary
CTI: Normal
Result: Normal Pulmo
LABORATORY EXAMINATION
WBC : 23,7 x 103/mm HB : 16,4 gr/dl PLT : 312.000 HCT : 49,7 % GDS : 123 mg/dl Ureum : 15 mg/dl Creatinin : 0,8 mg/d PT : 21,7 (0,8) APTT : 52,4 (26,6)
CK : 281 U/L CKMB : 22 U/L Trop. T : 0,02 Na : 141 mmol/l K : 4,2 mmol/l Cl : 107 mmol/l SGOT : 31 U/L SGPT : 34 U/L Albumin : 4,0 gr/dl
DIAGNOSIS
- STEMI Inferioposterior + Right Ventricular onset 2 hours KILLIP I
INITIAL MANAGEMENT Bed rest
O2 2-4 LPM (via nasal canule)
IVFD NaCl 0,9% loading 500 cc/24 hours
Anti Platelet Aggregation ASA (Aspilet) loading dose 160 mg (2 x 80 mg) maintenance 1-
0-0 Clopidogrel (Plavix) loading dose 300 mg (4 x 75 mg)
maintenance 0-1-0
ACEI
Captopril 3 x 6,25 mg
Anti cholesterol HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg)
Trombolitik
— Streptokinase (Streptase 1,5 million units were dissolved in 100 ml of Dextrose 5% in drips for 1 hour)
Anxiolytic Benzodiazepin (Alprazolam 1 x 0,5 mg)
Laxative Laxadin syrup 1 x 2 cth
ELECTROCARDIOGRAPHY Post Trombolitik 1 hour
PLANNING
Echocardiography Coronary angiography
ACUTE CORONARY SYNDROME
DIAGNOSIS OF CHEST PAIN
3 point typical chest painTend to be Stable Angina Pectoris than Acute Coronary
Syndrome
2 point atypical chest painTend to be Acute Coronary Syndrome than Non
Cardiac Chest Pain
1 point or none non cardiac chest pain
Retrosternal or substernal chest pain
1 poin
tIncreased by activity or emotion
1 poin
tRelieved by resting or nitrate SL
1 poin
t
DEFINITION
Acute Coronary Syndrome (ACS) is a term
for situations where the blood supplied to the
heart muscle is suddenly blocked.
describe a group of conditions resulting
from acute myocardial ischemia
(insufficient blood flow to heart muscle)
ranging from unstable angina
(increasing,
unpredictable chest pain) to
myocardial
infarction (heart attack).
CLASSIFICATION
ANATOMY
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
PATHOPHYSIOLOGY
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
Lipid transport disorder Inflamation
Plaque deposition
Stable plaque Plaque ruptureErosion
Stable angina pectoris Thrombosis
Thrombus
Acute coronary syndrome:• Unstable angina• Myocardial infarction :
- Non Q waves- Q waves
PATHOGENESIS
RISK FACTOR
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
Non- Modifiable Modifiable
Smoking
Hypertension
Diabetes Mellitus
Dyslipidemia
Obesity
Lack of physical activity
At least 2 of the following:
DIAGNOSIS OF ACS
1. Ischemic symptoms
2. Diagnostic ECG changes
3. Serum cardiac marker elevations
• Prolonged pain (usually >20
minutes) – constricting,
crushing, squeezing
• Usually retrosternal location,
radiating to left chest, left arm;
can be epigastric
• Dyspnea
• Diaphoresis
• Palpitations
• Nausea/vomiting
1. ISCHEMIC SYMPTOMS
2. DIAGNOSTIC ECG CHANGES
ECG CHANGES Timing of myocardial infarction based on ECG
3. SERUM CARDIAC MARKER ELEVATIONS
Troponin T CK-MB
CK Myoglobin
CARDIAC BIOMARKER
No
Yes
YesNo
STEMIAcute Myocardial
Infarction( Q-wave, non-Q wave )
NSTEMI(No ST-Segment Elevation
Myocardial Infarction)
Unstable Angina
Signs of myocardial ischemia
ST segmen elevation ?
Biochemical cardiac markers ?
DIAGNOSIS
ECG
Lab
INITIAL TREATMENT
1. Bed Rest
2. Diet
3. Oxygen (2-4L/mnt)
4. Anti platelet therapy : • Aspirin 160-325 mg chewed immediately and 81-162
mg continued indefinitely.• Clopidogrel 300-600 mg loading dose and 75 mg daily
continued for at least 14 days and up to 12 months
5. Nitroglycerin ISDN 10 mg or 20 mg, 2-3 a day. ISDN 5 mg SL when chest pain.
INITIAL TREATMENT
6. Morphine 2,5-5 mg or pethidin 12,5-25 mg iv
7. ACE I (Captopril 12,5-25 mg )
8. Fibrinolytic therapy:
a) Streptokinase 1.5million units iv
b) Tenecteplase 0.5mg/kg body weight iv.
9. Anticoagulation therapy:
a) Low Molecular Weight Heparins ( Fondaparinux) 2.5mg/24hrs/sc for up to 8 days post-MI.
10.Statins
Simvastatin 20 mg
THROMBOLYTIC AGENT INDICATIONS
Age < 70 yo Typical chest pain, > 20 minutes,
not relieved by nitrat ST elevation > 0,1 mV, on 2 lead or
more Onset < 12 hours
THROMBOLYTIC AGENT CONTRAINDICATIONS
Absolute:• Previous intracranial
haemorrhage or stroke of unknown origin at any time
• Central nervous system damage or neoplasms
• Recent major trauma/surgery/head injury (within the preceding 3 weeks)
• Gastrointestinal bleeding within the past month
• Known bleeding disorder (excluding menses)
• Aortic dissection
Relative: Transient ischaemic attack in
the preceding 6 months Oral anticoagulant therapy Pregnancy or within 1 week
postpartum Refractory hypertension
(systolic blood pressure >180 mmHg and/or diastolic blood pressure >110 mmHg)
Advanced liver disease Infective endocarditis Prolonged or traumatic
resuscitation
PROGNOSISKILLIP CLASSIFICATION
Class
DescriptionMortality Rate (%)
INo clinical signs of heart failure
6
IIRales or crackles in the lungs, an S3, and elevated jugular venous pressure
17
III Acute pulmonary edema 30 - 40
IV
Cardiogenic shock or hypotension (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction
60 – 80
PROGNOSIS – TIMI SCORE
Historical
Age 65-74 >/= 75
2 points3 points
DM/HTN or Angina 1 point
Exam
SBP < 100 3 points
HR > 100 2 points
Killip II-IV 2 points
Weight > 67 kg 1 point
Presentation
Anterior STE or LBBB 1 point
Time to treatment > 4 hrs 1 point
Risk Score = Total (0-14)
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%
9-14 35.9%
RIGHT VENTRICEL INFARCTION• RVI is common complication of Inferior Myocard
Infarct.• CORE study 2001 explained that RVI has many
complication, such as shock, tachycardia or fibrilation ventricel and atrioventricular block.
• Inferior Myocardial Infarction + RVI has mortality rate until 25%-30%, and without RVI the rate is 6% only.
• Guidelines ACC/AHA for STEMI 2004 tells that we have to be careful by giving nitrat, because it can decreases preload and can cause moderate hypotension.
• RVI therapy: inhalation nitric oxide, work as pulmonary vasodilator, can recover hemodynamic condition for Shock RVI patient.
MANAGEMENT
Maintaining preload right ventricel by using fluid
Avoid nitrat, diuretik, or morfin. Hypotension & bradycardi atropin
& fluid (50 cc/10 min) Nitric oxide inhalation
THANK YOU