ST-ELEVATION MYOCARDIAL INFARCTION

(1)

ST-ELEVATION

(2)

DEFINISI

Infark miokard akut adalah nekrosis miokard yang disebabkan oleh tidak adekuatnya pasokan darah akibat sumbatan akut arteri koroner.

IMA dengen elevasi segmen ST merupakan bagian dari spektrum Sindroma koroner akut.

(3)

Major Risk Factors (Exclusive of LDL

Cholesterol) That Modify LDL Goals

 Cigarette smoking

 Hypertension (BP 140/90 mmHg or on antihypertensive medication)

 Low HDL cholesterol (<40 mg/dL)†

 Family history of premature CHD

 _{CHD in male first degree relative <55 years}  CHD in female first degree relative <65 years

 Age (men 45 years; women 55 years)

† _{HDL cholesterol}_{60 mg/dL counts as a “negative” risk}

factor; its presence removes one risk factor from the total count.

(4)

Life-Habit Risk Factors

 _{Obesity (BMI}₃₀₎  _{Physical inactivity}  _{Atherogenic diet}

(5)

Emerging Risk Factors

 _{Lipoprotein (a)}  _Homocysteine

 _{Prothrombotic factors}  _{Proinflammatory factors}  _{Impaired fasting glucose}  _{Subclinical atherosclerosis}

(6)

(7)

Foam Cells Fatty Streak Intermediate Lesion Atheroma Fibrous Plaque Complicated Lesion/Rupture Endothelial dysfunction Smooth muscle and collagen

From first decade From third decade From fourth decade

Growth mainly by lipid accumulation Thrombosis, _haematoma

Adapted from Stary HC et al. Circulation 1995;92:1355-1374.

Atherosclerosis Timeline

(8)

Dislipidemia - Atherosclerosis

--- CVD

A Progressive Disease

CRP=C-reactive protein; LDL-C=low-density lipoprotein cholesterol.

Libby P. Circulation. 2001;104:365-372; Ross R. N Engl J Med. 1999;340:115-126.

Monocyte _LDL-C Adhesion molecule Macrophage Foam cell Oxidized LDL-C Plaque rupture Smooth muscle cells CRP Plaque instability and thrombus Oxidation Inflammation Endothelial dysfunction

(9)

Atherothrombosis: Thrombus Superimposed

on Atherosclerotic Plaque

(10)

Myocardial Hypoxia

↓ ATP

Impaired Na+_{, K}+_{- ATPase} ↑ Anaerobic metabolism

↑ Extracellular K+ ↑ Intracellular Na+ ↑ Intracellular Ca++

Altered membrane potential Arrhytmias Intracellular edema ↑ Intracellular H+ Chromatin clumping Protein denaturation CELL DEATH ↓ ATP ↑ Proteases ↑ Lipases

Adapted from Naik H, Sabatine MS, Lilly LS, 2007. Acute

Coronary Syndrome. In: Lilly LS, ed. Pathophysiology of Heart

(11)

(12)

Diagnosis of Acute MI

STEMI / NSTEMI



_{At least 2 of the}

following

 _{Ischemic symptoms}  _{Diagnostic ECG} changes

 Serum cardiac marker elevations

(13)

Pemeriksaan Penunjang

1. EKG

(14)

ECG assessment

ST Elevation or new LBBB

STEMI

Non-specific ECG

Unstable Angina

ST Depression or dynamic T wave inversions

NSTEMI

(15)

Diagnosis Banding

1. perikarditis akut

2. Emboli paru

3. Diseksi aorta akut

4. Kostokondritis

(16)

Acute Management

 _{Initial evaluation & stabilization}  _{Efficient risk stratification}

(17)

Chest pain suggestive of

ischemia

 _{12 lead ECG}  Obtain initial cardiac enzymes  _{electrolytes, cbc} lipids, bun/cr, glucose, coags  CXR

Immediate assessment within 10 Minutes

 Establish diagnosis  Read ECG  Identify complication s  Assess for reperfusion Initial labs and tests Emergent care History & Physical  IV access  Cardiac monitoring  Oxygen  Aspirin  Nitrates

(18)

Focused History

 _{Aid in diagnosis and}

rule out other causes

 _{Palliative/Provocative} factors  _{Quality of discomfort}  Radiation  _{Symptoms associated} with discomfort

 _{Cardiac risk factors}  Past medical history

-especially cardiac  _Reperfusion questions  _{Timing of} presentation  _{ECG c/w STEMI}  _{Contraindication to} fibrinolysis

(19)

Terapi

 _{Aspirin 150-300 mg}  _{Clopidogrel 300 mg}  _{Oksigen 2-4 L}  _{Nitrat sublingual}  _{Morfin 2-5 mg intravena}

 _{Penilaian dan stabilisasi hemodinamik}  _{Monitoring EKG}

 _{Nilai kemunkinan reperfusi (fibrinolitik atau}

(20)

Komplikasi

 _Aritmia

 _{Syok kardiogenik}  _{Edema paru akut}  _Perikarditis

(21)

Prognosis

 _Killip

(22)

(23)

DATA PRIBADI

 _{Nama pasien} _{: Tn. N. Pasaribu}

 _Umur _{: 49 Tahun}

 _{Jenis kelamin} _{: Laki-Laki}

 _Pekerjaan _{: Wiraswata}

 _Alamat _{: Desa Simorangkir}

 _Agama _{: Kristen}

 _{Tanggal Masuk} _{: 15 April 2011}

(24)

ANAMNESA

 _KeluhanUtama _{: Nyeri dada}  _Anamnese _:

hal ini dialami pasien sejak 2 hari sebelum masuk rumah sakit. Nyeri seperti terbakar di dada kiri dan menjalar ke rahang

bawah. Awalnya nyeri dirasakan setelah pasien berkebun. Nyeri tersebut tidak berkurang dengan beristirahat. Keringat dingin tidak dijumpai. Pasien mengeluh mual selama serangan, mual (-). Setelah 4 jam os merasakan nyeri yang terus-menerus, os berobat ke praktek dokter umum di Tarutung, dan os

dinyatakan menderita sakit jantung. Os diberikan ISDN oleh dokter di Tarutung tersebut dan kemudian os dirujuk ke RS di Medan. Nyeri dirasakan sedikit berkurang setelah diberi ISDN. Kemudian os berobat ke praktek dr. P. ManikSp.JP(K) dan oleh dokter tersebut os dirujuk ke RS HAM.

Saat tiba di UGD RS HAM, pasien masih mengeluhkan nyeri di dada kirinya. Riwayat sesak nafas, jantung berdebar, kaki

(25)

Riwayat merokok dijumpai sejak kira-kira 25 tahun lalu, setengah bungkus per hari. Os sudah 8 tahun terakhir berhenti merokok. Konsumsi alkohol dan tuak dijumpai. Os menderita sakit asam urat selama 5 tahun ini

 _{Faktor resiko PJK} _{: laki-laki, obesitas,}

ex-smoker, DM (-), hipertensi (-), riwayat PJK dalam keluarga (-)

 Riwayat Penyakit Terdahulu : asam urat

(26)

PEMERIKSAAN FISIK

KeadaanUmum : lemah Status present : C M TD : 100/60 mmHg HR : 85 x/i RR : 24x/i Temp : 36,5ºC Anemia (-) Sianosis (-) Ikterus (-) Dyspnoe (-) Edema (-) Ortopnoe (-)

(27)

 _{Kepala: mata :konjungtivapalpebra inferior}

pucat (-/-), sclera ikterik (-/-), RC (+/+) pupil isokor ka=ki

 _Leher _{: JVP R+2 cmH}₂_O

 _{Thorax :}

 _Inspeksi _{: Simetrisfusiformis}  Palpasi: SF ka = ki, kesannormal

 Perkusi : sonordikedualapanganparu

(28)

 _Jantung:

Batas atas :ICS III sinistra

Batas kanan:Linea sternalisdextra ICS V Batas kiri :1cm medial LMCS ICS V

S1 (N), S2 (N), S3 (-), S4 (-) Regulitas: reguler Murmur - Punctum maximum : -Radiasi: -

(29)

 Paru: SP : vesikuler ST :Rongkibasah(-) wheezing (-)  _Abdomen:  Palpasi: soepel  H/L/R : tidakterabapembesaran  Asites: (-)  Ekstremitas :

 Superior : sianosis (-), clubbing finger (-)

 Inferior : oedemapretibial (-), pulsasiarteri (+/+), akralhangat

(30)

 _{Interpretasi EKG}

EKG TARUTUNG

 SR, QRS rate 79x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III, AVF; Q path. : - , T inverted -, LVH -, RVH -, VES –  _{Kesan : SR + STEMI} inferior

(31)

 _{INTERPRETASI EKG}

EKG RS HAM (CVCU)

 SR, QRS rate 64x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST elevasi : III,

AVF; Q path. : III, AVF T inverted II, III, AVF; LVH

-, RVH -

 _{Kesan : SR + STEMI}

(32)

 _{INTERPRETASI FOTO} THORAX  _{CTR: 50%, Segemen} Aorta danpulmonal : Normal, , PinggangJantung : (-), Apex downward, Kongesti (+), Infiltrat (-).  _{KESAN : normal}

(33)

HASIL LABORATORIUM

DarahLengkap :  Hb : 17 g %  Eritrosit : 5, 92 x 106_/mm3  Leukosit : 14,4 x 103_/mm3  Hematokrit : 52,9 %  Trombosit : 223 x 103_/mm3 AGDA :  pH : 7,425  pCO2 : 32,1 mmHg  pO2 : 108,9 mmHg  HCO3 : 21,3 mmol/L

 Total CO2 : 21,5 mmol/L

 BE : -2,6 mmol/L  SaO2 : 98,2% FaalHati  SGOT : 130 U/L  SGPT : 46 U/L Troponin– T : 1,8 CK-NAC :805 CK-MB :77 Glukosadarahsewaktu : 142 mg/dL Ginjal  Ureum : 36 mg/dL  Kreatinin : 0,72 mg/dL Elektrolitserum

 Natrium (Na) : 127 mEq/L

 Kalium (K) : 4,8 mEq/L

(34)

 _DIAGNOSA

Diagnosis kerja:

STEMI inferior onset 2 harikillip I TIMI risk 2/14

 _Fungsional _: _{KILLIP I}

 _Anatomi: _{Right Coronary Artery}  _{Etiologi:arterosklerosis}

(35)

PENGOBATAN  Bedrestsemifowler  O2 2-4 L/I  Inj.enoxaparin0,6 cc/12 jam (5 hari)  Clopidogrel 4x75mg, selanjutnya 1x 75 mg  Aspilet2x80mg, selanjutya 1x 80 mg  ISDN 3x5mg  Simvastatin 1x40mg  Captopril3x6,25mg  Morfin 2,5 mg IV  RENCANA PEMERIKSAAN SELANJUTNYA  Lipid profile  Angiografikoroner  PROGNOSIS  Vitam : dubia ad bonam

 Functionam : dubia ad bonam

 Sanactionam : dubia ad bonam

(36)

(37)

(38)

FOLLOW UP EKG

 13 April 2011 (RS TARUTUNG)

SR, QRS rate 79x, QRS axis : normo axis, P wave (+)

normal, PR interval 0.16”, QRS duration 0,08, ST elevasi

: III, AVF; Q path. : - , T inverted -, LVH -, RVH -, VES –

Kesan: SR + STEMI inferior

 _{15 April 2011 (IGD RS HAM, Pukul 18.11)}

: III, AVF; Q path. : III, AVF , T inverted II, III, AVF ;LVH

-, RVH -, VES –

Kesan: SR + STEMI inferior

 _{15 April 2011 (CVCU, Pukul 19.00)}

: III, AVF; Q path. : III, AVF T inverted II, III, AVF; LVH -,

RVH -,VES-

(39)

 16 April 2011 (Ruangan, Pukul 05.15)

SR, QRS rate 63x, QRS axis : normo axis, P wave (+) normal, PR interval 0.16”, QRS duration 0,08, ST

elevasi : III, AVF; Q path. : III, AVF; T inverted II, III, AVF; LVH -, RVH -,VES-

Kesan : SR + STEMI inferior

 18 April 2011 (Ruangan, Pukul 07.00)

SR, QRS rate 73x, QRS axis : normo axis, P wave (+) normal, PR interval 0.2”, QRS duration 0,08, ST

elevasi : (-); Q path. : III , T inverted II, III, AVF; LVH

-, RVH -, VES –

(40)