CASE REPORT CARDIOLOGY DEPARTMENT

ANTEROSEPTAL WALL STEMI WITH ONSET >12 HOURS KILLIP I

Presented by: WINARSI C11108353
Supervisor: dr. Pendrik Tandean, Sp. PD-KKV, FINASIM
CARDIOLOGY DEPARTMENT MEDICAL FACULTY MAKASSAR 2013

PATIENTS IDENTITY
NAME : Mrs. IS AGE : 47 years old GENDER : Female MR : 60-54-18 Day of Admission : April 22nd, 2013

HISTORY TAKING
CHIEF COMPLAINT: Chest pain Structural Anamnesis: It was felt 1 day (onset >12 hours since 9 pm) before admitted to the hospital. The pain was felt on the left side of the chest with the characteristics of dull heavy feeling of the chest, duration of pain was > 30 minutes, radiated to the left arm and to the back. The pain exacerbated with exercises and did not lessen with rest or medication. Chest pain accompanied by shortness of breath. Dyspnea on effort (+) Orthopnea (-) Paroxysmal Nocturnal Dyspnea (-) Patient usually slept with 1-2 pillows. Cough (-) Fever (-) Nausea (+) Vomit (+) Palpitation (-) Cold sweats (+)

PAST MEDICAL HISTORY

History of diabetes melitus (-) History of hypertension (+) since 1 year ago with uncontrolled therapy. History of smoking (-) History of cardiovascular disease in family (-)

RISK FACTORS
Cigarette smoking (-) Alcohol consumption(-) Hypertension(+) Diabetes (-) History of Cardiovascular disease (-) Thyroid disease (-) History of cardiovascular disease and thyroid disease in family (-)

PHYSICAL EXAMINATION
General Status: Moderate illness/ Well nourished/ Conscious Nutritional Status: Normal (BMI: kg/m)
Weight : 60 kg Height : 160 cm BMI: 23.4 kg/m2

Vital Signs: Blood Pressure Pulse Rate Respiratory Rate Temperature

: : : :

170/110 mmHg 68 tpm 20 tpm 36.7 0C

Head and Neck Examinations: Eye : Conjunctiva: anemic (-/-), Sclera: icteric (-/-) Lip : Cyanosis (-) Neck : JVP R +2 cmHO Chest Examination Inspection : Symmetric between left and right chest.

Palpation
Percussion Auscultation

: No mass, no tenderness.
: Sonor between left and right chest, lungliver border in ICS IV right anterior . : Respiratory sound: Vesicular Additional sound: Ronchi -/-,Wheezing -/-

Cardiac Examination
Inspection Palpation Percussion : invisible heart apex : Heart apex was not palpable : Right heart border in right parasternal line, one finger lateral from left medioclavicular line : Heart Sounds : S I/II regular, murmur (-) gallop(-)

Auscultation

Abdominal Examination
Inspection Auscultation Palpation Percussion : Flat, following breath movement : Peristaltic sound (+), normal : No mass, no tenderness, no palpable liver or spleen. : Tympani (+)

Extremities Examination
Pretibial edema -/ Dorsal pedis edema -/-

ELECTROCARDIOGRAM (ECG) 22/04/2013

ECG Interpretation
Rhythm HR / QRS rate Axis Regularity P wave PR interval QRS complex ST segment T wave : Sinus Rhythm : 75 times/min : Normal : Regular : 0,08 s : 0,16 s : 3 small squares (0,12 s) : ST elevation at V1-V4 : T inverted on lead I, II, aVL, V5, V6

Conclusion : Sinus rhythm, HR 75 times/min, normoaxis, anteroseptal infarction and high lateral ischemic

LABORATORY FINDINGS (22/04/2013)

COMPLETE BLOOD COUNT Test WBC RBC Result 7.21 x 103/ul 4.06 x 106/l Normal value 4.0 10.0 x 103 4.0 6.0 x 106

HGB
HCT

11.2 gr/dl
34.4 %

12 16
37 48

PLT

209 x 103 /l

150 400 x 103

LABORATORY FINDINGS (22/04/2013)

BLOOD CHEMISTRY Test GDS Ureum Creatinine SGOT SGPT Total Chol HDL Chol TG Result 122 mg/dl 33 mg/dl 0,9 mgr/dl 184 u/l 27 u/l 278mg/dl 48 mg/dl 66 mg/dl Normal value <140 10 50 < 1.3 <38 <41 <200 > 55 <200

LABORATORY FINDINGS (22/04/2013)

CARDIAC ENZYMES Test CK Result 180 U/L Normal value <167

CK-MB
Troponin-T

90 U/L
>2,0

<25
Negative

CHEST X-RAYS 22/04/2013

Conclusion: Cardiomegaly (CTI: 0.59) Dilatation and elongation of aorta.

ECHOCARDIOGRAM 23/04/2013

Description of Wall Motion, Masses, Valves, Pericardium

Conclusion: Systolic and diastolic dysfunction, LV EF 43 %. LVH (+) Anterior mid septal hypokinetic, septal basal akinetic Moderate MR, Mild AR.

WORKING DIAGNOSIS

ANTEROSEPTAL WALL STEMI WITH ONSET >12 HOURS KILLIP I

MANAGEMENT
O2 2 -4 Lpm IVFD NaCl 0,9% 500cc/day Cedocard 1 mg/hour/SP Nitrat Arixtra 2,5 mg/24 hour/sc LMWH (Low Molecule Weight Heparin) Aspilet 80 mg 0-0-1 Aspirin (Antiplatelet) Plavix 75 mg 0-0-1 Clopidogrel (Antiplatelet) Captopril 25 mg 1-1-1 ACE-Inhibitor Simvastatin 20 mg 0-0-1 Statin (Anticholesterol) Laxadyn syr 0-0-2c Laxative Ranitidine 1 amp/12h/IV H2-antagonists Alprazolam 0,5 mg 0-0-1 Antianxietas Fluid balance

PLANNING
ECG per day

Discussion
ST ELEVATION MYOCARDIAL INFARCTION

INTRODUCTION
An acute myocardial infarction is caused by necrosis (irreversible) of myocardial tissue due to ischemia, usually due to blockage of a coronary artery by a thrombus.

PATHOPHYSIOLOGY
Occurs when coronary

blood flow decreases abruptly after a thrombotic occlusion of a coronary artery previously affected by atherosclerosis. In most cases, infarction occurs when an atherosclerotic plaque fissures, ruptures, or ulcerates.

CLASSIFICATION

ACS describe a group of conditions resulting from acute myocardial ischemia (insufficient blood flow to heart muscle) ranging from unstable angina to myocardial infarction.

DIAGNOSIS
Clinical history of ischemic type chest pain lasting for more than 20 minutes

WHO Diagnostic Criteria

Rise and fall of serum cardiac biomarkers such as creatine kinase-MB fraction and troponin Changes in serial ECG tracings

Oxford Handbook of Clinical Medicine 6th Edition

RISK FACTORS
Modifiable:
Hypertension Diabetes Mellitus Dyslipidemia Smoking Obesity

Non-modifiable:
Gender: male Age >45 years old Personal history of Coronary Artery Disease Family history of Coronary Artery Disease

DIAGNOSE????
Signs of myocardial ischemia

ECG
Yes

ST segment elevation?
No

ST-elevation Myocardial Infarction

Lab
Yes

Biochemical cardiac markers ?

No

NSTEMI ( Non ST-Elevation Myocardial Infarction )

Unstable Angina

KILLIP CLASSIFICATION
Class Description Mortality Rate (%)

I II

no clinical signs of heart failure rales or crackles in the lungs, an S3, and elevated jugular venous pressure acute pulmonary edema cardiogenic shock or hypotension (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction

6 17

III IV

30 - 40 60 80

THERAPY
Managing chest pain and anxiety o Bed rest o Diet o O2 2-4 lpm o Nitrate sublingual/oral/IV o Antiplatelet: aspirin and clopidogrel o Morphine/ pethidine Stabilizing hemodynamic (blood pressure and peripheral pulse control) o-blocker oCalcium channel blocker (CCB) oACE-Inhibitor Reperfusion of the myocardium oThrombolytic

PROGNOSIS KILLIP CLASSIFICATION

Class I II Description no clinical signs of heart failure rales or crackles in the lungs, an S3, and elevated jugular venous pressure
Mortality Rate (%) 6

17

III
IV

acute pulmonary edema

cardiogenic shock or hypotension (systolic BP < 90 mmHg), and evidence of peripheral vasoconstriction

30 - 40
60 80

TIMI PROGNOSIS IN STEMI

Risk Factor Age > 65 years old Age > 75 years old Score 2 3 1/1/1 3 2 2

History of angina/hypertension/DM Systolic BP <100 Heart rate > 100 Killip II-IV Weight > 67kg Anterior MI or LBBB Delay treatment >4hours

1 1 1

Total Score 0 1 2 3 4 5 6 7 8 9-16

Risk of Death in 30 days 0.8% 1.6% 2.2% 4.4% 7.3% 12.4% 16.1% 23.4% 26.8% 35.9%

COMPLICATION of MYOCARDIAL INFARCTION