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Presented by:MUHAMMAD IDHAM BIN MOKHDZIR
Supervisor :
dr. Pendrik Tandean, Sp.PD KKV, FINASIM
Department of Cardiology and Vascular MedicineMedical Faculty of Hasanuddin University
Makassar
2013
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PATIENT IDENTITY Medical Record : 622386
Name : Mr. IH
Gender : MaleAge : 43 years old
Address : Sudiang
Date of admission : August 18th2013
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HISTORY TAKING Chief complaint:
Chest Pain
History of Present Illness:
The chest pain began since 4 days before he was admitted to Wahidin
Sudirohusodo Hospital. The sensation of chest pain suddenly appeared when the
patient was playing video game. The pain is described like dull heavy feeling on the
left part of the chest, not spreading . The chest pain felt continuously more than 20
minutes duration, and not relieved by rest. The chest pain was accompanied with cold
sweat and feeling nauseated. Theresno history of any chest pain before. Theresalsono history of fever, high blood pressure, and diabetes. History of any heart disease in
the family denied. Patient been smoking for almost 20 years with 12 cigarette each
days .
Patient has history of epigastric pain. Urination and defecation were normal.
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HISTORY TAKING History of Past Illness:
History of chest pain (-)
History of smoking ( + ) for 20 years
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
History of epigastric pain (+)
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RISK FACTOR
Gender: Male
Age: 43 yo
NonModifiable
Smoking (+)
Modifiable
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PHYSICAL EXAMINATION General Status
Moderate illness/normal weight/conscious
Vital Signs BP : 110/60 mmHg
HR : 82 bpm, regular
RR : 20 tpm Temp : 36.6C
Weight : 60 kg
H eight : 166 cm
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PHYSICAL EXAMINATION Head Examination
Eyes : Anemic -/-, Icterus -/- Lips : Cyanosis (-)
Neck : Lymphadenopathy (-), JVP R+0 cmH2O
Thorax Examination Insp. : Symmetrical R=L , normochest Palp. : Mass (-), tenderness (-), Vocal Fremitus R=L
Perc. : Sonor Ausc. : Vesicular
Ronchi -/-,Wheezing -/-
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PHYSICAL EXAMINATION
Cardiac Examination Insp. : IC not visible
Palp. : IC not palpable
Perc. : Dull
Right border : Right parasternalis line
Left border : ICS 5 midclavicularis line
Ausc. : Pure regular of I/II heart sound, murmur (-)
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PHYSICAL EXAMINATIONAbdominal 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 Interpretation:
Rhythm : Sinus ritme P-Rate : x/m QRS-Rate : HR 68 bpm, reguler P-Wave : 0.12 sec PR-Interval : 0.20 sec QRS Complex : 0.08 sec Axis : Normal axis 50 ST-Segment : ST-elevation on lead I and AvL
ST-elevation on lead V2, V3, V4 , V5,V6 T-Wave : Normal
Conclusion: Sinus Rythmn, HR 65 bpm, normoaxis . ST-elevation onlead I ,AvL and lead V2-V6. Acute Extensive Myocardiac Infarct
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LABORATORY EXAMINATION
WBC : 17.71 HB : 14,1 gr/dl
PLT : 300.000 HCT : 38,1 % GDS : 131 mg/dl Ureum : 19 mg/dl
Creatinin : 1,1 mg/d Bil. Tot : 0,48 mg/dl Bil. Direct : 0,14 mg/dl
CK : 5581 U/L CKMB : 457 U/L Trop. T : >2.0 Na : 145 mmol/l K : 4,5 mmol/l Cl : 109 mmol/l SGOT : 17 U/L SGPT : 22 U/L Albumin : 4,0 gr/dl PT : 9.9 APTT : 23.9
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DIAGNOSIS
- STEMI Extensive Anterior with 4 hour onsetKillip I
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INITIAL MANAGEMENT
Bed rest O22-4 LPM (via nasal canule)
Heart Diet
IVFD NaCl 0,9% loading 500 cc/24 hours
Thrombolytic
Streptokinase (Streptase) 1.5 million IU in 100ml D5% within 1 hours
Anti Platelet Aggregation ASA (Aspilet) loading dose 80 mg (2 x 80 mg) maintenance 1-0-0
Clopidogrel (Plavix) loading dose 75 mg (4 x 75 mg) maintenance 0-1-0
Anti cholesterol
HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg) 0-0-1
Anti coagulant
Low Molecule Weight Heparin(Fondaparinux(Arixtra)) 2,5 mg/24 jam/SC
Anxiolytic
Benzodiazepin (Alprazolam 1 x 0,5 mg)
Laxative
Laxadin syrup 1 x 2 cth
Anti hypertension
Ace-inhibitor (Captopril) 3 x 12,5 mg
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PLANNING Echocardiography
Coronary angiography
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DIAGNOSIS OF CHEST PAIN
3 point typical chest painTend to be Stable Angina Pectoris than Acute CoronarySyndrome
2 point atypical chest painTend to be Acute Coronary Syndrome than NonCardiac 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 coronary arteryocclusion 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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RISK FACTOR
Non- Modifiable Modifiable
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
Smoking
Hypertension
Diabetes Mellitus
Dyslipidemia
Obesity
Lack of physical activity
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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
TroponinT CK-MB CK
SGOT LDH Myoglobin
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CARDIAC BIOMARKER
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DIAGNOSIS
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WHO DIAGNOSTIC CRITERIA
Clinical historyof ischaemictype chest pain lasting >20minutes
Changesin serial ECGtracings
Riseof serum cardiacbiomarkerssuch as creatininekinase-MB fraction and troponin
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INITIAL MANAGEMENT
Fixing the chest pain and fearness Bed rest
Diet
O2 2-4 lpm
Nitroglycerin: 0,4 mg SL tablets every 3-5 minutes up to 3 times; if effect is notsustained, can continue with an IV drip of 50 mg in 250 ml dextrose 5%
Antiplatelet :
Aspirin: 162-325 mg chewed immediately and 81-162 mg continued indefinetely
Clopidogrel 300-600 mg loading dose and 75 mg daily continued for at least 14days and up to 12 months.
Morphine 2-5 mg IV every 5-30 minutes
Pethidine 12,5 mg/IV
Diazepam 2-5mg/8 hour
Stabilizing the hemodynamic (blood pressure and pheripheral pulse control) -blocker
Calcium channel blocker (CCB)
ACE-Inhibitor
Reperfusion of the myocard
Thrombolytic: streptokinase 1,5 million units/IV
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PROGNOSIS
KILLIP CLASSIFICATIONClass Description Mortality Rate (%)
I No clinical signs of heart failure 6
IIRales or crackles in the lungs, an S3, andelevated jugular venous pressure
17
III Acute pulmonary edema 30 - 40
IVCardiogenic shock or hypotension(systolic BP < 90 mmHg), and evidenceof peripheral vasoconstriction
60 80
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