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STEMI

1. This document describes a case of a 62-year-old male patient presenting with chest pain and diagnosed with ST elevation myocardial infarction (STEMI). 2. The patient's history, physical exam findings, lab and imaging results are presented and support the diagnosis of inferior and posterior STEMI. 3. Acute coronary syndrome and STEMI are defined and risk factors, diagnostic criteria, treatment options and prognosis are discussed.

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72 views28 pages

STEMI

1. This document describes a case of a 62-year-old male patient presenting with chest pain and diagnosed with ST elevation myocardial infarction (STEMI). 2. The patient's history, physical exam findings, lab and imaging results are presented and support the diagnosis of inferior and posterior STEMI. 3. Acute coronary syndrome and STEMI are defined and risk factors, diagnostic criteria, treatment options and prognosis are discussed.

Uploaded by

GP HMH
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PPTX, PDF, TXT or read online on Scribd
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ST Elevation Myocardial

Infarction

Created by:
Suriyanti Listin (C11109295
Supervisor:
DR. dr. IDAR MAPPANGARA, SPPD, SPJP,
FIHA
CARDIOLOGY DEPARTMENT
MEDICAL FACULTY OF HASANUDDIN UNIVERSITY
MAKASSAR 2014
Patient Identity

 Name : Mr. Bs
 Age : 62 years old
 Gender : male
 Address : BTN Minasaupa
 Medical Record : 651823
 Date of Admission: February 20th, 2014
History Taking
CHIEF COMPLAIN
Chest Pain

PRESENT ILLNESS HISTORY

Left chest pain felt since 4 days ago and felt the last 2 days
before hospital admission, such as burning and pain radiating
to the left arm. Duration ± 10 minutes and felt at rest. Cold
sweat (+) and a sense of palpitations (+) especially when chest
pain. Dizziness (-) and headache (-). Cough (-) and mucus (-).
Shortness of breath (-), previous history of shortness of
breath (-). Nausea (-), vomiting (-), heartburn (-). Normal
urination and defecation
Previous Illness History
History of diabetes mellitus (-)
History of hypertension (-) since 2 years ago and took
medicine Iregularly
History of dyslipidemia (-)
History of smoking (+)
History of chest pain before (-)
History of heart diseases (-)
Family history with heart disease (-)
Risk Factors
Modifiable Risk Non-modifiable
Factor Risk Factor

Diabetes
Female
Mellitus

> 60
years old
Physical Examination
GENERAL
APPEARANCE
- Moderate Illness/Well Nourished/ Composmentis
- Body Weight : 50 kg
- Body Height : 150 cm
- Body Mass Index (BMI) : 22.2 kg/m2

VITAL SIGN
– BP : 160/90 mmHg
– HR : 80 x/min
– RR: 16x/min
– T : 36.70 C
REGIONAL STATE
 Head Examination
- Eyes : Anemis -/-, icterus -/-
- Lip : Cyanosis (-)
- Neck : JVP R -1 cmH2O
 Chest Examination
- Inspection : Symmetric right = left, normochest
- Palpation : No mass, no tenderness
- Percussion : Sonor, lung-liver border in ICS VI right
anterior
- Auscultation : Breath sound : Vesicular
Additional sound : Ronchi -/-
wheezing -/-
 Cardiac Examination
- Inspection : Ictus cordis invisible
- Palpation : Ictus cordis impalpable
- Percussion : Right heart border in right parasternal
line, left heart
border in left midclavicle line ICS V
- Auscultation : Regular of I/II heart sound, no murmur
 Abdominal
- Inspection : flat, following breath movement
- Auscultation : Peristaltic sound (+), normal
- Palpation : No mass, no tenderness, liver and spleen
unpalpable
- Percussion : tymphani, ascites (-)
 Extremities
- Oedema pretibial -/-
- Oedema dorsum pedis -/-
Continue…
Chest X-Ray (19/1/2014)
 Result

Dilatation et elongation
aorta and sign of lung
congestion
ECG (19/1/2014)

• Rhythm : Sinus Rhythm


 Heart Rate : 100 x/ minute
 Axis : Normoaxis
 P Wave : 0.08 s
 PR Interval : 0.12 s
 QRS Duration : 0.06 s
 ST Segment : ST Elevasi lead
I, aVF, V5-V9
 T inverted :Lead
II,III,aVF,V5-V9
Result : Sinus Rhythm, Heart Rate
100x/minute, Normoaxis, Inferior et
posterior infarction
Laboratory Findings (19/1/2014)

Complete Blood Count


Test Result Normal
value
WBC 17,8 x 103/uL 4.0 – 10.0 x
103
RBC 4,61 x 106/uL 4.0 – 6.0 x
106
HGB 13,7 g/dL 12 – 16
HCT 41,4% 37 – 48
PLT 382x 103/uL 150 – 400 x
103
Continue…
Blood Chemistry &
Cardiac Enzymes
Tes Hasil Nilai Normal
GDS 98 mg/dL <140
SGOT 142 u/L <38
SGPT 43 u/L <41
Ureum 41 10-50
Kreatinin 1,2 0,5-1,2
Kolesterol total 231 mg/dl 200
Kolesterol HDL 32 mg/dl L(<55) P (<65)
Kolesterol LDL 174 mg/dl <130
CK 1399 L (<190), P (<167)
CK-MB 88,9 <25
Troponin T 0,92 <0,05
Working Diagnosis

Inferior Posterior
ST Elevation Myocardial Infarction
Onset > 24 hours KILLIP I
Therapy
 O2 4 lpm via nasal canul
 IVFD Nacl 0,9 % 500 cc/24 hour
 Anti-Platelet: Aspilet 80 mg (loading dose 2x80 mg)
Clopidogrel 75 mg (loading dose 4x75 mg)
 Nitrat: Farsorbid 5 mg/SL(K/P)
Farsorbid 10 mg 3x1
 Statin: Simvastatin 1x 20 mg
   ARB (Angiotensin Receptor Blocker) : Valsartan 1x80
mg
 Anti-anxietas: Alprazolam 0,5 mg 0-0-1
 Laxative: Laxadyn syr 0-0-2 C
Planning
Echocardiography
Angiography
Discussion

Acute Coronary Syndrome


(ST Elevation Myocardial Infarction)
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:
Non-Modifiable Modifiable

Gender and Age Smoking

Hypertension
Family History

Diabetes Melitus

Dyslipidemia

Risk Factors Obesity


Diagnosis of ACS
At least 2 of the following :

1. Ischemic symptoms

2. Diagnostic ECG changes

3. Serum cardiac marker elevations


1. Ischemiac Symptoms
• Duration of chest pain > 20 minutes, at substernal area
• Substernal chest pain / chest discomfort radiated to the left arm,
shoulder, neck, jaw
• Not fully relieved by rest or nitroglycerine

• The chest discomfort may also be described as a dull


pain ,‘pressure’, ‘squeezing’ or ‘crushing sensation’ or burning
sensation

• Associated features including palpitation, sweating,


breathlessness, and nausea.
2. Diagnostic ECG Changes
3. Serum Cardiac Marker Elevation

CK CK-MB

Troponin
T
Diagnosis
Signs of myocardial ischemia

ECG
Yes STEMI
ST segmen elevation ? Acute Myocardial Infarction
( Q-wave, non-Q wave )

No Lab
Yes
Biochemical cardiac markers ?
NSTEMI
(No ST-Segment Elevation
Myocardial Infarction)
No
Unstable Angina
Therapy
 Bed rest
 Diet
 O2 2-4 lpm via nasal prongs
 Nitrat:
 ISDN 10 mg or 20 mg, 2-3 a day.
 ISDN 5 mg SL when chest pain.
 Antiplatelet:
• Aspirin 160-325 mg chewed immediately and 80-160 mg
continued indefinitely.
• Clopidogrel 300-600 mg loading dose and 75 mg daily continued
 Trombolitic: (if onset < 6 hours)
1,5 million unit IV in a hour
Prognosis
KILLIP CLASSIFICATION

Class Description Mortality Rate


(%)
I no clinical signs of heart failure 6
II rales or crackles in the lungs, an S3, 17
and elevated jugular venous pressure
III acute pulmonary edema 30 - 40
IV cardiogenic shock or hypotension 60 – 80
(systolic BP < 90 mmHg), and
evidence of peripheral
vasoconstriction
TIMI PROGNOSIS
Risk Factor Score
Age > 65 years old 2 Risk of
Total
  >/= 75 3 Death in 30
Score
days
History of 1
0 0.8%
angina/hipertension/DM
1 1.6%
2 2.2%
Systolic BP <100 3
3 4.4%
Heart rate >100 2 4 7.3%
Killip II-IV 2 5 12.4%
Weight >67 kg 1 6 16.1%
Anterior MI or LBBB 1 7 23.4%
8 26.8%
Delay treatment >4 hours 1
9-14 35.9%

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