livia sagita ruslim cardio stemi.ppt
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ST Elevation Myocardial Infarction(STEMI)
Inferior Onset 7 hours, KILLIP I
By:Livia Sagita Ruslim
Supervisor :
dr. Pendrik Tandean, Sp PD-KKV. FINASIM
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PATIENT IDENTITY
Name : Mr. AR
Gender : Male
Age : 54 years old
Address : Perintis Kemerdekaan street, Makassar
Registration no. : 618014
Date of admission : 08th July 2013
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ANAMNESIS
Chief Complaint: Chest pain
Present Illness History :
The chest pain began for + 7 hours before he was admitted to
Wahidin Sudirohusodo hospital, occurred when he was cleaning
a post. The pain is described like dull heavy feeling on the chest,
continuously, did not radiate to back and left arm and the pain
not improved by resting. The chest pain accompanied with
dizziness and cold sweating a lot.
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ANAMNESIS
Nausea (-), vomiting (-)
Cough ( - ), Shortness of breath ( - ), Fever (-)
Dyspnea on effort (-), Paroxysmal nocturnal dyspnea(-)
Urination normal
Defecation normal
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ANAMNESIS
Previous Illness History
History of heart disease ( - )
History of hypertension (-)
History of diabetes melitus (-)
History of dyslipidemia (-)
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ANAMNESISPersonal History
Smoking (+) 2 packs/ day for 30 years
Alcohol (+) 3L/ day for 10 years STOP
Family History
Father () old aged
Mother () old aged
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ANAMNESIS
RISK FACTOR
Modified Risk Factor
History of smoking (2 packs of cigarette/day for 30 years)
Non-modified risk factor:
Gender : male
Age : 54 year old
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PHYSICAL EXAMINATION
General appearance : Moderate illness/well nourished/composmentis
Vital Signs:
BP : 110/70 mmHg RR : 22 x/min BW : 97kg
HR : 84x/min T : 36,6C H : 173cm
Head : Anemia (-) , Icterus (), Palpebra Edema (-)
Neck : JVP R+0 cmH20
Lung : Vesikuler Rhonchi -/- Wheezing -/-
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PHYSICAL EXAMINATION
Cor : I : Ictus cordis not visible
P : Ictus cordis not palpable
P : Dull, normal heart size
-Upper border : left 2nd ICS
-Right border : right parasternalis line
-Left border : left medioclavicular line
- Lower border : left 5th ICS
A : Heart Sound I/II pure regular, murmur(-)
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PHYSICAL EXAMINATION
Abdomen :
Inspection : symmetrical big and following breath
movement
Auscultation : peristaltic sound (+) , normal
Palpation : liver and spleen unpalpable, mass (-)
Percussion : tympani, ascites (-)
Extremities : Edema -/-
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CHEST X-RAY (9th July 2013)
Cor : expand with CTI:0.59, waist of heartconcaved, apex lifted
(RVE), aorta dilatation Result : Cardiomegaly
with aorta dilatation.
a
b
c
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ECG FINDINGS
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Rhythm : AV Block
Frequency : 45 x/ minute
Axis : Normoaxis
P Wave : 0.08s
PR Interval : 0.36s
QRS Complex : 0.06s
ST Segment : ST Segments Elevation in leads II, III, aVF
T Wave : T wave inverted in leads III
Conclusion : Inferior Acute Myocardial Infarction, AV Block 1stdegree
ECG INTERPRETATION
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EChocardiography
LV systolic function decreased --- EF 33.90%
LVH (+) --- IVSd 17.7mm
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Complete blood count
WBC : 10.86 x 103/ul
RBC : 4.92 x 106/uL
HGB : 11.7 gr/dl
HCT : 34.8%
PLT : 261 x 103/l
Enzymes
CK :603 U/L
Trop T : 0.34
Coagulation Time
PT : 11.6s
APTT : 24.5s
Blood chemistry
Ureum : 42 mg/dl
Creatinine : 1.6 mg/dl
SGOT : 37 u/dl
SGPT : 14 u/ dl
GDS : 120 mg / dl
Uric acid : 6.5 mg / dl
Cholesterol total : 188 mg/dl
HDL : 32 mg / dl
LDL : 138 mg / dl
Triglyceride : 159mg / dl
LABORATORIUM FINDINGS
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DIAGNOSIS
STEMI Inferior onset 7 hours, Killip I
AV Block 1stdegree
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INITIAL MANAGEMENT
Bed rest
O2 2-4 lpm ( via nasal canule )
IVFD NaCl 0,9% 500cc/24 jam
Streptokinase 1.5million U / iv
Arixtra 2.5mg/24hrs/sc
Aspilet 162 mg qd (chewed) loading dose
Clopidogrel (Plavix) 4x75 mg qd
loading dose
Simvastatin 20 mg qd
Laxadin syr 1x2cth
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ADVISE
Coronary Angiography
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ACUTE CORONARY
SYndrome
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DEFINITION
Acute coronary syndromes (ACS) is the clinical
manifestation of the critical phase of coronary
artery disease.
Based on ECG and biochemical markers it is
distinguished from :
1)ST elevation myocardial infarction (STEMI)
2)Non-ST elevation myocardial infarction
(NSTEMI)
3)Unstable Angina
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PATHOPHYSIOLOGY
American Heart Association: http://watchlearnlive.heart.org
1 2 3
4 5 6
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PATHOPHYSIOLOGY
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Non-Modifiable
Gender and age.
Men, older than age 45
Women, older than age 55
Family history
Anyone with a 1stdegreemale or female relative who
developed CAD before age 55
or 65.
Modifiable
Smoking
Hypertension
Diabetes Mellitus
Dyslipidemia
Obesity
A desentary lifestyle
Stress
Risk factors
Overbaugh KJ. Acute Coronary Syndrome. AJN. May 2009: 109 (5):43
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ACUTE CORONARY SYNDROME
Daga LC, Kaul U, Mansoor A. Approach to STEMI and NSTEMI. Supplement to JAPI. 2011
(59):19.
Diff U t bl A i NSTEMI STEMI
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Differences Unstable Angina NSTEMI STEMI
Cause Thrombus partially orintermittently occludes the
coronary a.
Thrombus partially or
intermittently occludes the
coronary a.
Thrombus fully occludes the
coronary a.
Signs and
symptoms
chest pain with/without
radiation to arm, neck, back or
epigastric region
Shortness of breath, diaphoresis,nausea, lightheadedness,
tachycardia, tachypnea,
hypotension/ hypertension, SaO2and rhythm abnormalities
Occurs at rest or with exertion;
limits activity
chest pain with/without
radiation to arm, neck, back or
epigastric region
Shortness of breath, diaphoresis,nausea, lightheadedness,
tachycardia, tachypnea,
hypotension/ hypertension, SaO2and rhythm abnormalities
Occurs at rest or with exertion;
limits activity
Longer in duration and more
severe than in UA
chest pain with/without
radiation to arm, neck, back or
epigastric region
Shortness of breath, diaphoresis,nausea, lightheadedness,
tachycardia, tachypnea,
hypotension/ hypertension, SaO2and rhythm abnormalities
Occurs at rest or with exertion;
limits activity
Longer in duration and more
severe than in UA (infarction
occurs if perfusion is not restored)
Diagnostic Findings ST-segment depression or T-waveinversion on ECG
Cardiac biomarkers not elevated
ST-segment depression or T-wave
inversion on ECG
Cardiac biomarkers are elevated
ST-segment elevation or new
LBBB on ECG
Cardiac biomarkers are
elevated
Treatment O2 to maintain SaO2 level >90%Nitroglycerin or morphine to
control pain-blockers, angiotensin-
converting enzyme inhibitors,
statins, c`lopidogrel, LMWH, and
glycoprotein Iib/IIIa inhibitors
O2 to maintain SaO2 level >90%
Nitroglycerin or morphine to
control pain-blockers, angiotensin-
converting enzyme inhibitors,
statins, clopidogrel, LMWH, and
glycoprotein Iib/IIIa inhibitors
Cardiac catheterization and
possible PCI for patients with
ongoing chest pain,
hemodynamic instability, or
increased risk of worsening
clinical condition
O2 to maintain SaO2 level >90%
Nitroglycerin or morphine to
control pain-blockers, angiotensin-
converting enzyme inhibitors,
statins, clopidogrel, LMWH
PCI within 90 minutes of
medical evaluation
Fibrinolytic therapy within 30
minutes of medical evaluation
Anderson JL, et al. Circulation 2007;116(7):e148-e304; Hazinski MF, et al., editors.Handbook of emergency cardiovascular care for healthcare providers.
Dallas:American Heart Association; 2008.
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RISK SCORE FOR ACS
TIMI Risk Score for NSTEMI
Historical
Age 65 1
3 risk factors for CAD 1
Known CAD (Stenosis 50%) 1Aspirin use in past 7 days 1
Presentation
2 anginal events in 100 2 points
Killip II-IV 2 points
Weight < 67 kg 1 point
Presentation
Anterior STE orLBBB
1 point
Time to rx > 4 hrs 1 point
Risk Score = Total (0-14)
Daga LC, Kaul U, Mansoor A. Approach to STEMI and NSTEMI.
Supplement to JAPI. 2011 (59):20.
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Management
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Initial Treatment
1. Bed Rest
2. Diet
3. Oxygen (2-4L/mnt)
4. Anti platelet therapy :
- Aspirin 162-325mg chewed immediately and 81-162 mg continued
indefinitely.
- Clopidogrel 300-600mg loading dose and 75mg daily continued for at least 14
days and up to 12 months.
5. Nitroglycerin
0.4 mg SL tablets every 3-5 min up to 3 times; if effect is not sustained, cancontinue with an IV drip of 50mg in 250mL Dextrose 5%.
2013 ACC/AHA Guideline STEMI
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Initial Treatment
6. Morphine 2-5mg iv Q5-30min
7. Fibrinolytic therapy:
a) Streptokinase 1.5million units iv
b) Tenecteplase 0.5mg/kg body weight iv
8. Anticoagulation therapy:
a) Low Molecular Weight Heparins ( Fondaparinux)
2.5mg/24hrs/sc for up to 8 days post-MI.
9. Statins
Simvastatin 20mg qd
Options for Transport of Patients With
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Options for Transport of Patients With
STEMI and Initial Reperfusion Treatment
EMS Transport
Onset of
symptomsof STEMI
9-1-1
EMSDispatch
EMS on-scene
Encourage 12-lead ECGs. Consider prehospital fibrinolytic
if capable and EMS-to-needle
within 30 min.GOALS
PCI
capable
Not PCI
capable
Hospital fibrinolysis:
Door-to-Needlewithin 30 min.
Inter-
HospitalTransfer
Golden Hour = first 60 min. Total ischemic time: within 120 min.
Patient EMS Prehospital
fibrinolysisEMS-to-needle
within 30 min.
EMS transport
EMS-to-balloon within 90 min.Patient self-transport
Hospital door-to-balloon
within 90 min.
5
min.
8
min.
Antman EM, et al. J Am Coll Cardiol 2008. Published ahead of print on December ;
ACC/AHA STEMI Guideline 2009
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PROGNOSIS
Class Description Mortality Rate(%)
I No clinical signs of heart failure 6
II Rales or crackles in the lungs, an S3, andelevated jugular venous pressure
17
III Acute pulmonary edema 30 - 40
IV Cardiogenic shock or hypotension(systolic BP < 90 mmHg), and evidenceof peripheral vasoconstriction
60
80
KILLIP CLASSIFICATION
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THANK YOU