Stemi Ppt 4f2s6q

NSTEMI (NON ST ELEVATION MYOCARDIAL INFARCTION) By: FAUZIAH Supervisor : DR. ABDUL HAKIM ALKATIRI, SPJP-FIHA DEPARTMENT OF CARDIOLOGY AND VASCULAR MEDICINE MEDICAL FACULTY OF HASANUDDIN UNIVERSITY MAKASSAR 2016

PATIENT IDENTITY  Name

: Ms. S

 Age

: 75 years old

 Occupation

: Farmer

 Address

: Moncongloe lappara, Maros

 MR  Date

: 727033 of ission

: January 13th 2016

HISTORY TAKING  Chief

complaint : Chest pain

 Present  Left

Illness History :

chest pain felt since 18 hours ago before ission

 Occurs

suddenly when the patient was in washroom

 Described

as oppressed pain and felt through the left arm, intermittently, duration of pain more than 20 minutes. With cold sweating.

 There

is orthopneu, and DOE.

 Cough,

no fever, no nausea and and no vomiting

HISTORY TAKING Past history:  history

of chest pain on and off

 History

of hypertention since 1 year ago

 History

of heart disease is none

 History

of Diabetes Mellitus is none

HISTORY TAKING  Personal

Life History :

 No

history of alcohol consumption

 No

history of smoking

 No

history of heart disease in the family

 No

history of diabetes in the family

 Past  No

Treatment History : history of hospital ission

PHYSICAL EXAMINATION 

General Status  Moderate

illness / well nourished/ Composmentis

 Weight

: 45 kg

 Height:  BMI 

155 cm : 18.7 kg/m2

Vital Status  Blood

pressure : 180/100 mmHg

 Heart

rate

 Respiratory

: 92 bpm rate : 26 rpm

 Temperature

: 36,5 oC

PHYSICAL EXAMINATION  Head

: anemic (-) icteric (-)

 Neck

: JVP R+2 cmH2O

 Lung

:

 Inspection

: symmetry left=right

 Palpation

: no tenderness, normal vocal fremity

 Percussion

: sonor

 Auscultation

: vesicular, ronchi +/+ at basal lung,

wheezing -/-

PHYSICAL EXAMINATION  Cor

:

 Inspection  Palpation

: ictus cordis not visible

: ictus cordis not palpable, thrill (-)

 Percussion Upper Right Left

:

border 2nd ICS sinistra

border 4th ICS linea parasternalis dextra

border 5th ICS linea axillaris anterior sinistra

 Auscultation

: heart sound I/II pure, regular, murmur (-)

PHYSICAL EXAMINATION  Abdomen

:

 Inspection

: flat, follows breath movement

 Auscultation

: peristaltic (+), normal

 Palpation

: liver and spleen not palpable

 Percussion

 Extremities  Edema

(-)

: tympani

:

ELECTROCARDIOGRAPHY Sinus tachycardia HR : 107bpm Regularity: regular Axis : normoaxis PR interval : 0.20 s QRS rate : 0.08 s QRS complex : S V1+ R V5/V6> 35mm ST segmen : ST segmen elevation on lead V1-V3 ST depresion on Lead I, aVL, V5, V6 Conclusion : Sinus tachycardia, HR : 107bpm, anteroseptal walls myocardial infarction, lateral wall ischemic.

LABORATORY RESULTS TEST

RESULT

NORMAL

TEST

RESULT

VALUE WBC

17.700 x 103/uL

4.0 – 10.0 x 103

NORMAL VALUE

Tot.Choles

238mg/dl

200

HDL

51 mg/dl

>59

RBC

4.6

4.0 – 6.0 x 106

LDL

171 mg/dl

130

HGB

12.1

12 – 16

Trigliserida

134 mg/dl

200

HCT

39

37 – 48

Ureum

40

10-50

PLT

279x 103/uL

150 – 400 x 103

Kreatinin

0.96

0,5-1,2

Troponin I

1.61

<0,01

CK

154,00

<190

CKMB

19.5

<25

Natrium

148

136 - 145

Kalium

3,1

3,5 - 5,1

Klorida

113

97 - 111

Asam Urat

-

3,4-7,0

PT

12.3

10 - 14

APTT

22.7

22,0 - 30,0

INR

1.18

GDS

363mg/dl

140

GD2PP

-

<200

SGOT

28 u/L

<38

SGPT

26 u/L

<41

CHEST X-RAY

Result : • Cardiomegaly with signs of pulmonary edema • Dilatatatio elongation et atherosclerosis aortae

DIAGNOSIS STEMI

onset >12 hours, KILLIP II Hipertension gr.I Stress hyperglycemia dd DM type II non obese hypokalemia

TREATMENT  Oksigen  IVFD

2-4 liter per menit via nasal kanul

NaCl 0,9% 500 cc/24 jam/IV

 Aspirin

160mg (loading dose) 80mg/24j/oral

 Clopidogrel  Isosorbid  Arixtra

300mg (loading dose) 75 mg/24 jam/oral

Dinitrat 10mg/jam/oral

2,5mg/24j/SC

 furosemide  Captopril

40mg/12jam/IV

12.5mg/8jam/oral

 Simvastatin

20 mg/24 jam/oral

 Alprazolam

0,5mg/24jam/oral

 Laxadyne  KSR

syr 10ml/24jam/oral

600mg/12jam/oral

DISCUSSION

INTRODUCTION  Acute

coronary syndromes (ACS)

is a term for situations where the blood supplied to the heart muscle is suddenly blocked. •

described as 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).

PATOPHYSIOLOGY

PATHOPHYSIOLOGY

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org



Normal myocardium metabolizes fatty acid and glucose to CO2 and H2O



Severe O2 depriviation, fatty acid cannot be oxidized and glucoseis degraded into lactate, intracellular pH is reduced, intramyocardial stores of high energy phosphates is reduced.



Impaired cell membrane function leads to leakage of K and uptake of Na by myocytes, as well as increase in cytosolic Ca.



As the results:



if total occlusion in the absence of collaterals is more than 20 mins, it can causes permanent myocardial necrosis



Electrical instability,which can lead to ventricular premature beats, ventricular tachycardia or ventricular fibrillation

Patophysiology

WHO DIAGNOSTIC CRITERIA Ischemic symptoms

• • • •

Prolonged chest pain Usually retrosternal location Dyspnea Diaphoresis

• • • •

Troponin-T CK-MB CK Myoglobin

Diagnostic ECG changes Serum cardiac marker elevations

RISK FACTORS

NonModifiable

Modifiable Smoking Hypertension Diabetes mellitus Hypercholesterolemia Obesity Psychosocial stress Lack of physical activity

Gender & Age • •

Men > 45 years old Women > 55 years old

Family history • Heart disease in biological brother or father > 55 years old • Heart disease in biological sister or mother > 65 years old

CARDIAC BIOMARKERS

GOAL OF TREATMENT

Relieve pain

Hemodynamic stabilization

Myocardial reperfusionn

Prevent the complication

Initial Treatment 

Bed rest



Oxygen (2-4 lpm)



Anti platelet therapy :





Aspirin 162-325mg chewed immediately and 81-162 mg continued indefinitely.



Clopidogrel 300-600mg loading dose and 75mg daily continued for at least 14 days and up to 12 months.

Nitroglycerin : 

0.4 mg SL tablets every 3-5 min up to 3 times; if effect is not sustained, can continue with an IV drip of 50mg in 250mL Dextrose 5%.



Morphine 2-5mg iv (can be istered again in 5-30 minutes later)



Fibrinolytic therapy:





Streptokinase 1.5million units iv



Actilyse 0.75mg/kg weight body

Anticoagulation therapy: 

Low Molecular Weight Heparins (Fluxum) 0.4cc/sc for up to 8 days post-MI.



Unfractionated heparin



Anti Hypertension Drugs



Lipid Lowering Agents

Complication

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