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Presented by:MUHAMMAD IDHAM BIN MOKHDZIR

Supervisor :

dr. Pendrik Tandean, Sp.PD KKV, FINASIM

Department of Cardiology and Vascular MedicineMedical Faculty of Hasanuddin University

Makassar

2013


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PATIENT IDENTITY Medical Record : 622386

Name : Mr. IH

Gender : MaleAge : 43 years old

Address : Sudiang

Date of admission : August 18th2013


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HISTORY TAKING Chief complaint:

Chest Pain

History of Present Illness:

The chest pain began since 4 days before he was admitted to Wahidin

Sudirohusodo Hospital. The sensation of chest pain suddenly appeared when the

patient was playing video game. The pain is described like dull heavy feeling on the

left part of the chest, not spreading . The chest pain felt continuously more than 20

minutes duration, and not relieved by rest. The chest pain was accompanied with cold

sweat and feeling nauseated. Theresno history of any chest pain before. Theresalsono history of fever, high blood pressure, and diabetes. History of any heart disease in

the family denied. Patient been smoking for almost 20 years with 12 cigarette each

days .

Patient has history of epigastric pain. Urination and defecation were normal.


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HISTORY TAKING History of Past Illness:

History of chest pain (-)

History of smoking ( + ) for 20 years

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

History of epigastric pain (+)


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RISK FACTOR

Gender: Male

Age: 43 yo

NonModifiable

Smoking (+)

Modifiable


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PHYSICAL EXAMINATION General Status

Moderate illness/normal weight/conscious

Vital Signs BP : 110/60 mmHg

HR : 82 bpm, regular

RR : 20 tpm Temp : 36.6C

Weight : 60 kg

H eight : 166 cm


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PHYSICAL EXAMINATION Head Examination

Eyes : Anemic -/-, Icterus -/- Lips : Cyanosis (-)

Neck : Lymphadenopathy (-), JVP R+0 cmH2O

Thorax Examination Insp. : Symmetrical R=L , normochest Palp. : Mass (-), tenderness (-), Vocal Fremitus R=L

Perc. : Sonor Ausc. : Vesicular

Ronchi -/-,Wheezing -/-


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PHYSICAL EXAMINATION

Cardiac Examination Insp. : IC not visible

Palp. : IC not palpable

Perc. : Dull

Right border : Right parasternalis line

Left border : ICS 5 midclavicularis line

Ausc. : Pure regular of I/II heart sound, murmur (-)


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PHYSICAL EXAMINATIONAbdominal 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 -/-


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ELECTROCARDIOGRAPHY


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ELECTROCARDIOGRAPHY Interpretation:

Rhythm : Sinus ritme P-Rate : x/m QRS-Rate : HR 68 bpm, reguler P-Wave : 0.12 sec PR-Interval : 0.20 sec QRS Complex : 0.08 sec Axis : Normal axis 50 ST-Segment : ST-elevation on lead I and AvL

ST-elevation on lead V2, V3, V4 , V5,V6 T-Wave : Normal

Conclusion: Sinus Rythmn, HR 65 bpm, normoaxis . ST-elevation onlead I ,AvL and lead V2-V6. Acute Extensive Myocardiac Infarct


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LABORATORY EXAMINATION

WBC : 17.71 HB : 14,1 gr/dl

PLT : 300.000 HCT : 38,1 % GDS : 131 mg/dl Ureum : 19 mg/dl

Creatinin : 1,1 mg/d Bil. Tot : 0,48 mg/dl Bil. Direct : 0,14 mg/dl

CK : 5581 U/L CKMB : 457 U/L Trop. T : >2.0 Na : 145 mmol/l K : 4,5 mmol/l Cl : 109 mmol/l SGOT : 17 U/L SGPT : 22 U/L Albumin : 4,0 gr/dl PT : 9.9 APTT : 23.9


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DIAGNOSIS

- STEMI Extensive Anterior with 4 hour onsetKillip I


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INITIAL MANAGEMENT

Bed rest O22-4 LPM (via nasal canule)

Heart Diet

IVFD NaCl 0,9% loading 500 cc/24 hours

Thrombolytic

Streptokinase (Streptase) 1.5 million IU in 100ml D5% within 1 hours

Anti Platelet Aggregation ASA (Aspilet) loading dose 80 mg (2 x 80 mg) maintenance 1-0-0

Clopidogrel (Plavix) loading dose 75 mg (4 x 75 mg) maintenance 0-1-0

Anti cholesterol

HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg) 0-0-1

Anti coagulant

Low Molecule Weight Heparin(Fondaparinux(Arixtra)) 2,5 mg/24 jam/SC

Anxiolytic

Benzodiazepin (Alprazolam 1 x 0,5 mg)

Laxative

Laxadin syrup 1 x 2 cth

Anti hypertension

Ace-inhibitor (Captopril) 3 x 12,5 mg


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PLANNING Echocardiography

Coronary angiography


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DIAGNOSIS OF CHEST PAIN

3 point typical chest painTend to be Stable Angina Pectoris than Acute CoronarySyndrome

2 point atypical chest painTend to be Acute Coronary Syndrome than NonCardiac Chest Pain

1 point or none non cardiac chest pain

Retrosternalor substernalchest pain

1point Increased by

activity oremotion

1point Relieved by

resting ornitrate SL

1point


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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).


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CLASSIFICATION


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PATHOPHYSIOLOGY

Vulnerable Plaque Thrombosis Vasospasme

Plaque disruption andthrombosis that result incomplete coronary arteryocclusion leads totransmural ischemia and

necrosis, the hallmark ofST-segment elevationmyocardial infarction(STEMI)


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Lipid transport disorder Inflamation

Plaque deposition

Stable plaque Plaque ruptureErosion

Stable angina pectorisThrombosis

Thrombus

Acute coronary syndrome:

Unstable angina

Myocardial infarction :

- Non Q waves

- Q waves

PATHOGENESIS


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RISK FACTOR

Non- Modifiable 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

Smoking

Hypertension

Diabetes Mellitus

Dyslipidemia

Obesity

Lack of physical activity


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At least 2 of the following:

DIAGNOSIS OF ACS

1. Ischemic symptoms

2. Diagnostic ECG changes

3. Serum cardiac marker elevations


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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


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2. DIAGNOSTIC ECG

CHANGES


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ECG CHANGESTiming of myocardial infarction based on ECG


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3. SERUM CARDIAC MARKER

ELEVATIONS

TroponinT CK-MB CK

SGOT LDH Myoglobin


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CARDIAC BIOMARKER


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DIAGNOSIS


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WHO DIAGNOSTIC CRITERIA

Clinical historyof ischaemictype chest pain lasting >20minutes

Changesin serial ECGtracings

Riseof serum cardiacbiomarkerssuch as creatininekinase-MB fraction and troponin


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INITIAL MANAGEMENT

Fixing the chest pain and fearness Bed rest

Diet

O2 2-4 lpm

Nitroglycerin: 0,4 mg SL tablets every 3-5 minutes up to 3 times; if effect is notsustained, can continue with an IV drip of 50 mg in 250 ml dextrose 5%

Antiplatelet :

Aspirin: 162-325 mg chewed immediately and 81-162 mg continued indefinetely

Clopidogrel 300-600 mg loading dose and 75 mg daily continued for at least 14days and up to 12 months.

Morphine 2-5 mg IV every 5-30 minutes

Pethidine 12,5 mg/IV

Diazepam 2-5mg/8 hour

Stabilizing the hemodynamic (blood pressure and pheripheral pulse control) -blocker

Calcium channel blocker (CCB)

ACE-Inhibitor

Reperfusion of the myocard

Thrombolytic: streptokinase 1,5 million units/IV


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PROGNOSIS

KILLIP CLASSIFICATIONClass Description Mortality Rate (%)

I No clinical signs of heart failure 6

IIRales or crackles in the lungs, an S3, andelevated jugular venous pressure

17

III Acute pulmonary edema 30 - 40

IVCardiogenic shock or hypotension(systolic BP < 90 mmHg), and evidenceof peripheral vasoconstriction

60 80


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