cardio stemi.pptx

8/11/2019 cardio stemi.pptx

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STEMI W HOLE ANTERIOR O NSET


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PATIENT IDENTITY

Name : Mr. S

Gender : Male

Age : 43 years old

Address : Kerabat Kera-Kera

Registration number : 677672

Date of admission : 27 th August 2013


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ANAMNESIS

Chief Complaint : Chest pain

Present Illness History :

The chest pain began for + 3 hours before he was admitted to

Wahidin Sudirohusodo hospital, occurred when he was working

at office. The pain is described like dull heavy feeling on the

chest, continuously, radiate to back, left and right arms. The

chest pain accompanied with cold sweating a lot and palpitation.


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ANAMNESIS

Nausea (-), vomiting (-)

Cough ( - ), Shortness of breath ( - ), Fever (-)Dyspnea on effort (-), Paroxysmal nocturnal dyspnea(-)

, Orthopnea (-)

Urination normalDefecation 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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ANAMNESIS Personal History

History of smoking (+) 1 pack/day (stopsmoking + 2 years ago)

History of drinking alcohol 1 bottle/day (stop

drink alcohol + 10 years ago)


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PHYSICAL EXAMINATION

General appearance : Moderate illness/pre-obese/composmentis

Vital Signs:

BP : 150/100 mmHg RR : 20 x/min

HR : 90x/min T : 36,7 CWeight : 82 kgHeight : 170 cmBMI : 28,4 kg/m 2

Head : Anemia (-) , Icterus ( ), Palpebra Edema (-) Neck : JVP R+0 cmH 20 Lung : Vesicular Ronchi -/- Wheezing -/-


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Cor : I : Punctum Maximum Impulse not visible

P : Ictus cordis not palpable

P : Dull, normal heart size

-Upper border : left 2nd

ICS-Right border : right 4 th ICS parasternalis line

-Left border : left 5 th ICS medioclavicular line

A : Heart Sound I/II pure regular, murmur(-)


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Abdomen :Inspection : symmetrical big and following breath

movement

Auscultation : peristaltic sound (+) , normalPalpation : liver and spleen unpalpable, mass (-)Percussion : tympani, ascites (-)

Extremities : Edema -/-


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CHEST X-RAY

Result : There are noabnormalities in thisx-ray


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ECG FINDINGS

Conclusion :

Sinus rhytm HR 75 bpm, normoaxis . ST- elevation on lead V1-V6. Whole anteriormyocardial infarction .


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ECG I NTERPRETATION Rhythm : Sinus Rhythm

HR / QRS rate : 75 times/min Axis : NormoaxisRegularity : RegularP wave : 0,1 s

PR interval : 0,20 sQRS complex : 2 small squares (0,08 s)ST segment : ST Elevation V1-V6T wave : normal

Conclusion :Sinus rhytm HR 75 bpm, normoaxis . ST- elevationon lead V1-V6. Whole anterior myocardialinfarction .


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Complete blood count

RBC : 5,26 x 10 /uL

WBC : 11,8 x 10/uL

HGB : 15,8 g/dL

HCT : 45,8 %

PLT 248 x 10/uL

Enzymes

CK : 234 U/L

CKMB : 12.6 U/L

Troponin T : 0.27

Blood chemistry

Ureum : 23 mg/dl

Creatinine : 0.9 mg/dl

SGOT : 25 u/dl

SGPT : 25 u/ dl

GDS : 146 mg / dl

Uric acid : 5.9 mg / dl

Coagulation Time

PT : 10.5s

APTT : 24.2s

LABORATORIUM FINDINGS


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DIAGNOSISSTEMI Whole Anterior Wall onset


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INITIAL MANAGEMENT

O 2 2-4 liter per minute ( via nasal canule )IVFD NaCl 0,9% 500cc/24 hoursIsosorbide Dinitrate 5 mg/ sublingual (if there is chestpain)

Aspilet 160 mg (loading dose)Clopidogrel 300 mg (loading dose)Farsorbid 2 mg/hour/Syringe PumpCaptopril 25 mg 1-1-1

Actylise 100 mg (15 mg bolus intravena, 50 mg/30minutes/SP, 35 mg/60 minutes/SP)


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PLANNING Coronary Angiography


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Acute coronary syndromes (ACS) is an 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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STEMI requires evaluation for acutereperfusion intervention


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Silbernagl and Lang Colour Atlas of Phatophysiology. 2000


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Stable Angina

Unstable Angina Infraction


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Non Modifable

Gender and Age Men, increased risk

after age 45 Women, increased

risk after age 55 Family History

Heart diseasediagnosed before age 55in father or brother

Heart diseasediagnosed before age 65in mother or sister

Modifable

Smoking Hypertension Diabetis Mellitus Dyslipidemia Obesity Lack of physical activity


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Ischemicsymptoms

DiagnosticECG changes

Serum cardiacmarker elevations

Prolonged pain (usually >20 mins) constricting, crushing,squeezing

Usually retrosternal location,radiating to left chest, left arm;

can be epigastric Dyspnea Diaphoresis Palpitations Nausea/vomiting Light headedness

Sense of impending doom

Troponin T CK-MB CK

Myoglobin


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CARDIAC BIOMARKERS


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TIMI RISK SCORE FOR STEMI

Historical Age 65-74>/= 75

2 points3 points

DM/HTN or Angina 1 point

ExamSBP < 100 3 pointsHR > 100 2 pointsKillip II-IV 2 pointsWeight < 67 kg 1 point

Presentation

Anterior STE /LBBB 1 point

Time to rx > 4 hrs 1 point

Risk Score = Total (0-14)

RISK SCORE ODDS OFDEATH BY30D*

0 0.1 (0.1-0.2)1 0.3 (0.2-0.3)2 0.4 (0.3-0.5)3 0.7 (0.6-0.9)4 1.2 (1.0-1.5)5 2.2 (1.9-2.6)6 3.0 (2.5-3.6)7 4.8 (3.8-6.1)8 5.8 (4.2-7.8)

>8 8.8 (6.3-12)

* referenced to average mortality (95%confidence intervals)


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Relieve pain Hemodynamic stabilization

Myocardial reperfusion Prevent the complication


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1. Bed Rest2. Diet3. Oxygen (2-4L/minute)4. Anti platelet therapy :

Aspirin 162-325mg chewed immediately and 81-162 mgcontinued indefinitely.Clopidogrel 300-600mg loading dose and 75mg daily continuedfor at least 14 days and up to 12 months .

5. Nitroglycerin0.4 mg SL tablets every 3-5 min up to 3 times; if effect is notsustained, can continue with an IV drip of 50mg in250mL Dextrose 5%.

2013 ACC/AHA Guideline STEMI


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6. Morphine 2-5mg iv (can be administered again in

5-30 minutes later)7. Fibrinolytic therapy:

a) Streptokinase 1.5million units ivb) 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. Anti Hypertension Drugs10. Lipid Lowering Agents


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COMPLICATIONS

Sudden Death

Ventricular Dysfunction

Hemodynamic Disturbances

Cardiogenic shock

Pericarditis

Arrhythmia post STEMI


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Class Description Mortality Rate (%)

I No clinical signs of heart failure 6

II Rales or crackles in the lungs, an S 3, 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


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cardio stemi.pptx