STEMI - Pembacaan Kardio2

7/30/2019 STEMI - Pembacaan Kardio2

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Stemi Inferoposterior et RV

Onset 3 Hours Killip I

Presented by:

Muh. Ayyub Primadi

Supervisor :

dr. Abdul Hakim Alkatiri, Sp.JP, FIHA

Department of Cardiology and Vascular MedicineMedical Faculty of Hasanuddin University

Makassar

2013


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PATIENT IDENTITY

Medical Record : 622664

Name : Mr. R

Gender : Male Age : 31 years old

Address : Maros

Date of admission : 13 Agustus 2013


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HISTORY TAKING Chief complaint:

Chest Pain

History of Present Illness:

The chest pain began since 3 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.


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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


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RISK FACTOR

Gender:

Male

Non

Modifiable

Smoking (+)

Obesitas (+)

Modifiable


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PHYSICAL EXAMINATION

General Status

Moderate illness/obes 1/conscious

Vital Signs

BP : 130/80 mmHg

HR : 70 bpm, regular

RR : 22 tpm

T : 36.7C

BW : 82 kg

H :170 cm


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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 -/-


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Cardiac Examination

Insp. : IC wasnt visible Palp. : IC wasnt 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

(-)


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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 -/-


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ELECTROCARDIOGRAPHY


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ELECTROCARDIOGRAPHY


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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.ST-depretion on lead V2, V3, V4, V5, and V6

T-Wave : Normal

Conclusion: Sinus Rhythm, HR 75 bpm, RAD, inferoposterior and right ventricular acute myocardialinfarction, whole anterior ischaemic.


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CHEST X-RAY

14 Agustus 2013

Normal pulmonary

CTI: Normal

Result: Normal Pulmo


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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


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DIAGNOSIS

- STEMI Inferioposterior + Right

Ventricular onset 3 hours KILLIP I


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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

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


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ELECTROCARDIOGRAPHY

Post Trombolitik


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PLANNING

Echocardiography

Coronary angiography


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ACUTE CORONARY SYNDROME


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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

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 coronaryartery occlusion 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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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

Troponin T CK-MB CK

SGOT LDH Myoglobin


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CARDIAC BIOMARKER


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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


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MYOCARDIAL INFARCTION


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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.


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PATHOPHYSIOLOGY

Vulnerable Plaque Thrombosis

Vasospasme

Plaque disruption and

thrombosis that result in

complete coronary artery

occlusion leads to

transmural ischemia andnecrosis, the hallmark of

ST-segment elevation

myocardial infarction

(STEMI)


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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


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WHO DIAGNOSTIC CRITERIA

Clinical historyof ischaemictype chest pain lasting >20minutes

Changes in serial ECG tracings

Riseof serum cardiacbiomarkerssuch as creatininekinase-MB fraction and troponin


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CLINICAL HISTORY

Duration : variable, often more than 30 minutes.

Quality : Feels squeezing, pressurelike, tightness,

heaviness, and burning.

Location : Retrosternal, often with radiation to orisolated discomfort in neck, jaw, shoulders, or arms

frequently on left.

Associated features : Not relieve with rest or nitrat


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ECG CHANGESTiming of myocardial infarction based on ECG


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CARDIAC BIOMARKER


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DIAGNOSIS


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THROMBOLYTIC AGENTINDICATIONS

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


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THROMBOLYTIC AGENT

Absolute: Previous intracranial

haemorrhage or stroke ofunknown origin at any time

Central nervous systemdamage or neoplasms

Recent majortrauma/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 weekpostpartum

Refractory hypertension(systolic blood pressure >180mmHg and/or diastolic bloodpressure >110 mmHg)

Advanced liver disease

Infective endocarditis

Prolonged or traumaticresuscitation

CONTRAINDICATIONS


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PROGNOSIS

KILLIP CLASSIFICATION

Class DescriptionMortality Rate

(%)

I No clinical signs of heart failure 6

IIRales or crackles in the lungs, anS3, and elevated jugular venous

pressure

17

III Acute pulmonary edema 30 - 40

IV

Cardiogenic shock orhypotension (systolic BP < 90

mmHg), and evidence of

peripheral vasoconstriction

60 80


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PROGNOSIS TIMI SCORE

HistoricalAge 65-74

>/= 75

2 points

3 points

DM/HTN or Angina 1 point

ExamSBP < 100 3 points

HR > 100 2 points

Killip II-IV 2 points

Weight > 67 kg 1 point

PresentationAnterior STE or LBBB 1 point

Time to treatment > 4 hrs 1 point

Risk Score = Total (0-14)

Total

Score Risk of Deathin 30 days0 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%


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THANK YOU

STEMI - Pembacaan Kardio2

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