Case Report STEMI INFERIOR ONSET 15 JAM KILLIP I TIMI RISK 3/14

Pembicara - Ismail Lubis (080100152)

Pembimbing

dr.Parlindungan Manik,SpJP(K)

DEFINISI
Suatu sindroma klinik yang menandakan adanya iskemia miokard akut, terdiri dari : Infark miokard akut Q wave (STEMI) Infark miokard akut non-Q (NSTEMI) Angina pektoris tidak stabil (UAP)
Ketiga kondisi ini sangat berkaitan erat, berbeda hanya dalam derajat beratnya iskemi dan luasnya miokard yang mengalami nekrosis.

PATOGENESIS
Umumnya disebabkan aterosklerosis koroner oleh Plak aterosklerosis ruptur terbentuk trombus diatas ateroma yang secara akut menyumbat lumen koroner Apabila sumbatan terjadi secara total hampir seluruh dinding ventrikel akan nekrosis

FAKTOR RESIKO
Faktor resiko biologis yang tak dapat diubah : 1. Usia dan jenis kelamin 2. Ras 3. Riwayat keluarga

Faktor-faktor resiko yang masih dapat diubah

The cardiovascular continuum of events Ischemia = oxygen supply and demand imbalance
Myocardial Ischemia

CAD

plaque
Atherosclerosis

Risk Factors ( , BP, DM, DYSLIPIDEMI Insulin Resistance, Platelets, A Fibrinogen, etc)

The cardiovascular continuum of events

Coronary Thrombosis Myocardial Ischemia

CAD Atherosclerosis

Risk Factors ( DYSLIPIDEMIA, BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)

The cardiovascular continuum of events

ACS
Coronary Thrombosis Myocardial Ischemia

CAD Atherosclerosis

Risk Factors ( DYSLIPIDEMIA, BP, DM, Insulin Resistance, Platelets, Fibrinogen, etc)

DIAGNOSIS
Anamnesis EKG Biomarker Kerusakan Jantung

Minimal 2 SKA

HISTORY
PRODROMAL SYMPTOMS History very valuable to establish D/. Prodoma : chest discomfort unstable angina 1/3 symptoms for 1 4 wks 20% symptoms for < 24 hrs Malaise, exhaustion NATURE OF PAIN Most patients severe prolonged, 30 minutes - hours Constricting, crushing, oppressing, compressing heavy weight or squeezing in chest Choking, vise-like, heavy pain or stabbing, knife-like, boring or burning discomfort Location : retrosternal, spreading frequently to both sides of the chest with predilection to the left side Often pain radiates down ulnar aspect of left arm, producing tingling sensation in left wrist, hand and fingers

NATURE OF PAIN SOME INSTANCES : pain begins in epigastrium, and simulates abdominal disorder Sometimes pain radiates to shoulders, upper extremities, neck, jaw and interscapular region favoring the left side

Elderly : no chest pain but acute left ventricular failure and chest tightness or marked weakness or syncope
Pain arises from nerve endings in ischemic or injured, but not necrotic, myocardium OTHER SYMPTOMS 50% nausea or vomiting in transmural infarcts Occasionally diarrhea, profound weakness, dizziness, palpitation, cold perspiration, sense of impending doom Occasionally : cerebral embolism or systemic arterial embolism

Pain Patterns with Myocardial Ischemia

12

Anamnesis untuk UAP

3 kategori presentasi klinik UAP: Angina saat istirahat (resting angina) Angina awitan baru (new onset angina) Angina yang bertambah berat (increasing angina) Riwayat penyakit dahulu : Riwayat angina on effort, infark atau operasi pintas Riwayat penggunaan nitrogliserin Identifikasi faktor-faktor risiko

PHYSICAL EXAMINATION
GENERAL APPEARANCE Anxious, considerable distress, (Levine sign) LV failure & symp. stimulation : dyspnea, cough with frothy sputum. Shock : cool, clammy skin, confusion or disorientation
restless, fist on chest cold perspiration, pallor, pink or blood-streaked facial pallor, cyanosis,

HEART RATE Variable depending on underlying rhythm and degree or ventr. failure Most commonly, HR 100 110/min; > 95% patients : VPBs within first 4 hours

BLOOD PRESSURE Majority normotensive, but syst. BP may decline and diast. BP may rise Half of pts with inferior MI parasympathetic stimulation : hypotension, bradycardia or both (Bezold Jarisch reflex) half of pts with anterior MI, sympathetic excess : hypertension, tachycardia or both TEMPERATURE AND RESPIRATION Most pts with extensive MI fever within 24-48 hrs, fever resolves by 4th or 5th day Respiration due to anxiety and pain, in LV failure : resp. rate correlates with degree of heart failure

Pemeriksaan Penunjang
Pemeriksaan EKG
Gambaran EKG infark miokard akut Q-wave (STEMI) :

Elevasi segmen ST 1 mm pada 2 sadapan extremitas

Atau 2 mm pada 2 sadapan prekordial yang berurutan Atau gambaran LBBB baru atau diduga baru
16

Gambaran EKG infark miokard akut non-Qwave (NSTEMI) atau angina pektoris tidak stabil (UAP) :
Depresi segment ST atau gelombang T terbalik

pada 2 sadapan berurutan

Inversi gelombang T minimal 1 mm pada 2

sadapan atau lebih yang berurutan.

Perubahan segment ST saat keluhan dan

kembali normal saat keluhan hilang sangat menyokong UAP

T-wave inversion

LOKASI SKA

Biomarker Kerusakan Jantung

BIOMARKER WAKTU PUNCAK ELEVASI KEMBALI NORMAL

CK-MB

3 12 jam

24 jam

48 72 jam

(cTn)T

3 12 jam

24 jam

5 10 hari

(cTn)I

3 12 jam

12 jam 2 hari

5 14 hari

PENATALAKSANAAN

The cardiovascular continuum of events

ACS
Coronary Thrombosi s Myocardial Ischemia Arrhythmia and Loss of Muscle Remodeling

CAD Atherosclerosi s Risk Factors ( DYSLIPIDEMI , BP, DM, A Insulin Resistance, Platelets, Fibrinogen, etc)

Ventricular Dilatation Congestive Heart Failure End-stage Heart Disease

DELAY TO THERAPY

1. From onset of symptoms to patient recognition

2. Out-hospital transport

3. In-hospital evaluation

ISCHEMIC CHEST PAIN ALGORYTHM

Chest pain suggestive of ischemia

ISCHEMIC CHEST PAIN

TYPICAL ANGINA EQUIVALENT ANGINA

1. NO CHEST DISCOMFORT 1. CHEST DISCOMFORT

2. LOCATION
3. INDIGESTION 4. UNEXPLAINED WEAKNESS 5. DIAPORESIS 6. SHORTNESS OF BREATH

2. LOCATION
3. RADIATION 4. UNLIKELINESS

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment

Chest discomfort suggestive of ischemia

Immediate ED assessment ( 10 min)
Vital sign Oxygen saturation Obtain IV access Obtain ECG 12 lead Brief history and physical exam Check contraindication for fibrinolytic Initial serum cardiac markers Initial electrolyte and coagulation Memory: MONA greets all patients

Immediate ED general treatment

O2 at 4 L/min (maintain O2 sat 90%) Aspirin 160-325 mg Nitroglycerin SL, spray, or IV Morphine IV 2-4 mg repeated every 5-10 minutes (if pain not relieved with nitroglycerine)

study
Portable chest x-ray ( 30 minutes)

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or presumably new LBBB strongly suspicious for injury

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG

ST elevation or new or presumably new LBBB strongly suspicious for injury

ST-depression or dynamic T-wave inversion strongly suspicious for injury

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG
ST elevation or new or presumably new LBBB strongly suspicious for injury (STEMI) ST-depression or dynamic T-wave inversion strongly suspicious for injury (UA/NSTEMI) Normal or nondiagnostic changes in ST-segment or Twaves (intermediate/ low-risk UA)

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia

Immediate ED assessment and immediate ED general treatment

Review initial 12 lead ECG
ST elevation or new or presumably new LBBB strongly suspicious for injury (STEMI)
Start adjunctive treatment

ST-depression or dynamic T-wave inversion strongly suspicious for injury (UA/NSTEMI)

Normal or nondiagnostic changes in ST-segment or Twaves (intermediate/ low-risk UA)

ADJUNCTIVE TREATMENT (Do not delay reperfusion)

1. Beta-adrenergic receptor blocker 2. Clopidogrel 3. Heparin (UFH or LMWH)

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG

ST elevation or new or presumably new LBBB strongly suspicious for injury

Start adjunctive treatment Time from onset of symptoms

ST-depression or dynamic T-wave inversion strongly suspicious for injury

Normal or nondiagnostic changes in ST-segment or Twaves

12 hours
- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB - Statin

Acute coronary syndrome algorithm

Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG

ST elevation or new or presumably new LBBB strongly suspicious for injury

Start adjunctive treatment Time from onset of symptoms

ST-depression or dynamic T-wave inversion strongly suspicious for injury

Normal or nondiagnostic changes in ST-segment or Twaves

Start adjunctive treatment

12 hours
- Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB within 24 hours of onset - Statin

Adjunctive treatment
Heparin (UFH/LMWH)
Glycoprotein IIb/IIIa receptor inhibitors -Adrenoreceptor blockers Clopidogrel

Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG ST elevation or new or presumably new LBBB strongly suspicious for injury Start adjunctive treatment Time from onset of symptoms 12 hours - Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB within 24 h of symptom onset) - Statin - High risk: early invasive strategy - Continue ASA, heparin, ACE-I, statin ST-depression or dynamic T-wave inversion strongly suspicious for injury Normal or nondiagnostic changes in ST-segment or Twaves

Start adjunctive treatment

12 hrs Admit to monitored bed Assess risk status

VERY HIGH-RISK PATIENT

1. Refractory chest pain 2. Recurrent/persistent ST deviation 3. Ventricular tachycardia 4. Hemodynamic instability 5. Sign of pump failure 6. Shock within 48 hours

Chest discomfort suggestive of ischemia Immediate ED assessment and immediate ED general treatment Review initial 12 lead ECG ST elevation or new or presumably new LBBB strongly suspicious for injury Start adjunctive treatment Time from onset of symptoms 12 hours - Reperfusion strategy: PCI (90 min) or fibrinolysis (30 min) - ACE-I/ARB within 24 h of symptom onset) - Statin - High risk: early invasive strategy - Continue ASA, heparin, ACE-I, statin ST-depression or dynamic T-wave inversion strongly suspicious for injury Normal or nondiagnostic changes in ST-segment or Twaves Develops high or intermediate risk criteria or troponin-positive Monitored bed in ED Develops high or intermediate risk criteria or troponin-positive

Start adjunctive treatment 12 hrs Admit to monitored bed Assess risk status

No evidence of ischemia and MI: discharge with follow-up

Pengobatan Pasca Perawatan

Obat-obat untuk mengontrol keluhan iskemia harus dilanjutkan Aspirin Beta-blocker ACE inhibitor

Modifikasi Faktor Risiko

Berhenti merokok Pertahankan BB optimal Aktivitas fisik sesuai dengan hasil treadmill Diet Rendah lemak jenuh dengan kolesterol, bila perlu dengan target LDL < 100 mg/dL Pengendalian hipertensi Pengendalian ketat gula darah pada penderita DM

Get regular medical checkups. Control your blood pressure.

Check your cholesterol.

Dont smoke. Exercise regularly. Maintain a healthy weight. Eat a heart-healthy diet. Manage stress.

PROGNOSIS
FAKTOR RESIKO SKOR SKOR RISIKO MORTALITAS 30 HARI (%) Usia 65 74 tahun Usia > 75 tahun DM/ Hipertensi TD < 100 mmHg HR > 100 x Klasifikasi Killip II-IV (s3 dan atau ronkhi basah, edema paru, syok kardiogenik) 7. Berat < 67 kg 8. Elevasi ST anterior/ LBBB 9. Waktu reperfusi > 4 jam
1. 2. 3. 4. 5. 6.

2 3 1 3 2 2

0 0,8 % 1 1,6 % 2 2,2% 3 4,4 % 4 7,3 % 5 12,4 %

1 1 1

6 16,1 % 7 23,4 % 8 26,8 %

STATUS PASIEN
Rekam Medik No : 55.85.52 Tanggal : 08 Mei 2013 Hari : Rabu Nama : Sabam Manurung Umur : 55 tahun Seks : Lk Pekerjaan : TNI dan Polri Alamat : Jln. Taduan No 28 Agama : Katolik Kec Medan Tembung

 Keluhan Utama : Nyeri Dada Ananmnesa :Hal ini telah dialami Os lebih kurang 15 jam yang lalu.Rasa

sakit menetap hingga dibawa ke RSHAM.Os mengatakan nyeri muncul setelah berolahraga.Rasa sakit seperti terhimpit benda berat.Os juga mengeluhkan panas di ulu hati.Rasa sakit os menjalar hingga ke lengan,bahu dan punggung.Rasa sakit berkurang jika os dalam posisi duduk.Os juga mengeluhkan adanya keringat dingin.Os menyangkal adanya batuk.Os juga mengeluhkan mual dan muntah.Os mengatakan bahwa nyeri dada ini adalah yang pertama kalinya.Riwayat merokok(+) sejak 24 tahun yang lalu,os merokok 2 bungkus perhari..Riwayat hipertensi (-), DM(+).Os juga menyangkal adanya keluarga os yang mengalami keluhan yang sama Faktor Resiko PJK : Laki laki, Umur > 45 tahun, merokok, DM Riwayat Penyakit Terdahulu : DM Riwayat Pemakaian Obat : Tidak Jelas

STATUS PRESENS
KU : sedang Kesadaran : Compos mentis TD : 130/80 mmHg HR : 85 x/m RR : 20 x/m Suhu : 37 C

Sianosis (-) Ortopnu (-) Dispnu (-) Ikterus (-) Edema

(-) Pucat (-)

PEMERIKSAAN FISIK
Kepala : konjungtiva palpebra inferior pucat (-), ikterus (-) Leher : JVP R+2 cmH2O Dinding toraks : Inspeksi : simetris fusiformis

Palpasi : sf ka=ki Perkusi : sonor

Auskultasi

Batas Jantung : atas : ICR III kanan : LSD kiri : 1 cm lateral LMCS

Jantung : S1 (N) S2 (N) S3 (-) S4 (-) Reguler Murmur (-)

Tipe : PSM, MDM, EJ SM, EDM Grade (-) Punctum maximum : apeks Radiasi : aksila

 Paru : Suara pernafasan : Vesikuler

Suara Tambahan : Ronki basah basal (-) Wheezing (-) Abdomen : Palpasi Hepar/Lien: tidak teraba Asites (-) Ekstremitas : Superior : sianosis (-) clubbing (-) Inferior : edema (-) pulsasi arteri (+) Akral : Hangat

HASIL LABORATORIUM
Darah Lengkap (CBC) Hb : 14.50 g % RBC: 4570000 WBC :13500 Ht 41,5 % PLT :258000 MCV 93.50 fL MCH 31.70 pg MCHC 94.90 g% RDW 12.70 % MPV 8.90 fL PCT 0.24 % PDW 9.4 fL

 HATI

LDH 2053 U/L AST/SGOT 420 U/L ALT/SGPT 78 U/L METABOLISME KARBOHIDRAT Glukosa Darah (Puasa) 67 mg/dL Glukosa Darah (Sewaktu) 126 mg /dL HbA1C 5.9 % GINJAL Ureum 95.00 mg/dL Kreatinin 2.37 mg/dL ELEKTROLIT Natrium (Na)130 mEq/L Kalium (K) 3.8 mEq/L Klorida (Cl) 101 mEq/L ENZIM JANTUNG CK-MB 172 U/L

Diagnosa kerja Fungsional : STEMI Inferior Onset 15 Jam KILLIP I TIMI Risk 3/14 Anatomi : a. coroner Etiologi : aterosklerosis Pengobatan : Bed Rest O2 4-6 L/i IVFD Nacl 0,9% 10 gtt/i Loading Plavix 300 mg 1x 75 mg Loading Aspilet 160mg 1 x 80 mg Inj Lavenox 0,13 cc(IV) 0,6 cc /12 jam selama 5 hari Inj Pethidine 25 mg Alprazolam 1 x0,5 mg ISDN 3 x 5 mg Atorvastatin 1 x 40 mg Laxadin syr 3 x c1 Rencana pemerikasaan lanjutan : U/D/F Lengkap AGDA CKMB /Troponin T Ro Thoraks EKG Prognosis : Dubia ad bonam

 Interpretasi EKG: sinus rithym, QRS rate

72x/i,QRSdurasi 0,08 PR interval 0,24 p wave (N), ST-T Changes: ST-Elevasi di lead II,III.aVf, VES(-), LVH (-),Hiperakut T (T-Tall Wave) Kesan: SR + STEMI inferior + First Degree AV Block

 Interpretasi foto toraks (AP/PA) :

CTR 52% Ao normal, Po menonjol, Pinggang jantung normal, Apex downward, kongesti (-), infiltrat(-) Kesan : Mild cardiomegaly

FOLLOW UP

TERIMA KASIH