ST-ELEVATION MYOCARDIAL INFARCTION
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.
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.
Life-Habit Risk Factors Obesity (BMI 30) Physical inactivity Atherogenic diet
Emerging Risk Factors Lipoprotein (a) Homocysteine Prothrombotic factors
Proinflammatory factors Impaired fasting glucose Subclinical atherosclerosis
PATOFISIOLOGI STEMI
Atherosclerosis Timeline Foam Cells
Fatty Streak
Intermediate Atheroma Lesion
Fibrous Complicated Plaque Lesion/Rupture
Endothelial dysfunction From first decade
From third decade
Growth mainly by lipid accumulation
From fourth decade Smooth muscle and collagen
Thrombosis, haematoma
Adapted from Stary HC et al. Circulation 1995;92:1355-1374.
Dislipidemia ----- Atherosclerosis ---- CVD A Progressive Disease Plaque rupture
Monocyte
LDL-C
Adhesion molecule
Macrophage
Oxidized LDL-C Foam cell
CRP
Smooth muscle cells
Endothelial dysfunction
Inflammation
Oxidation
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.
Plaque instability and thrombus
Atherothrombosis: Thrombus Superimposed on Atherosclerotic Plaque
Adapted from Falk E, et al. Circulation. 1995;92:657-671.
Myocardial Hypoxia ↓ ATP
↑ Anaerobic metabolism
Impaired Na+, K+ - ATPase ↑ Extracellular K+
↑ Intracellular Na+
Altered membrane potential
Arrhytmias
↑ Intracellular Ca++
↑ Intracellular H+ Chromatin clumping Protein denaturation
Intracellular edema ↓ ATP ↑ Proteases ↑ Lipases
Adapted from Naik H, Sabatine MS, Lilly LS, 2007. Acute Coronary Syndrome. In: Lilly LS, ed. Pathophysiology of Heart Disease 4th Edition. USA: Lippincott Williams & Wilkins; 168-196
CELL DEATH
Pathology & ECG
Diagnosis of Acute MI STEMI / NSTEMI At least 2 of the
following Ischemic symptoms Diagnostic ECG changes Serum cardiac marker elevations
Time is muscle
Pemeriksaan Penunjang 1. EKG 2. Enzim jantung
ECG assessment ST Elevation or new LBBB STEMI ST Depression or dynamic T wave inversions
NSTEMI Non-specific ECG
Unstable Angina
Diagnosis Banding 1. perikarditis akut 2. Emboli paru 3. Diseksi aorta akut 4. Kostokondritis 5. Gangguan gastrointestinal
Acute Management Initial evaluation & stabilization Efficient risk stratification Focused cardiac care
Chest pain suggestive of ischemia Immediate assessment within 10 Minutes Initial labs and tests 12 lead ECG Obtain initial
cardiac enzymes electrolytes, cbc lipids, bun/cr, glucose, coags CXR
Emergent care IV access Cardiac monitoring Oxygen Aspirin Nitrates
History & Physical Establish diagnosis Read ECG Identify complication s Assess for reperfusion
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 Degree of STEMI risk
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 PCI Primer)
Komplikasi Aritmia Syok kardiogenik Edema paru akut Perikarditis
Prognosis Killip TIMI Risk
STATUS PASIEN
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 Berat badan : 95 kg ; Tinggi badan : 176 cm
ANAMNESA KeluhanUtama Anamnese
: Nyeri dada : 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 bengkak, pingsan, dan batuk tidak ditemui.
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, exsmoker, DM (-), hipertensi (-), riwayat PJK dalam keluarga (-) Riwayat Penyakit Terdahulu : asam urat Riwayat Pemakaian Obat : Tidak jelas
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 )
(-
Kepala: mata :konjungtivapalpebra inferior
pucat (-/-), sclera ikterik (-/-), RC (+/+) pupil isokor ka=ki Leher : JVP R+2 cmH2O Thorax : Inspeksi
: Simetrisfusiformis Palpasi: SF ka = ki, kesannormal Perkusi : sonordikedualapanganparu Auskultasi : vesikuler
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: -
Paru:
SP : vesikuler ST :Rongkibasah(-) wheezing
(-) Abdomen: Palpasi: soepel H/L/R : tidakterabapembesaran Asites: (-)
Ekstremitas
:
Superior : sianosis (-), clubbing finger (-) Inferior : oedemapretibial (-), pulsasiarteri (+/+),
akralhangat
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
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 inferior
INTERPRETASI FOTO THORAX CTR: 50%, Segemen
Aorta danpulmonal : Normal, , PinggangJantung : (-), Apex downward, Kongesti (+), Infiltrat (). KESAN : normal
HASIL LABORATORIUM DarahLengkap : Hb
: 17 g %
Eritrosit
: 5, 92 x 106/mm3
Leukosit : 14,4 x 103/mm3 Hematokrit : 52,9 %
Trombosit
: 130 U/L
: 46 U/L
: 7,425 : 32,1 mmHg : 108,9 mmHg
: 21,3 mmol/L : 21,5 mmol/L : -2,6 mmol/L
HCO3 Total CO2 BE
SaO2
: 98,2%
CK-NAC
:805
CK-MB
:77
Glukosadarahsewaktu : 142 mg/dL
pH pCO2 pO2
SGPT
Troponin– T : 1,8
: 223 x 103/mm3
AGDA :
FaalHati SGOT
Ginjal
Ureum : 36 mg/dL Kreatinin
: 0,72 mg/dL
Elektrolitserum
Natrium (Na) Kalium (K)
: 127 mEq/L : 4,8 mEq/L
Klorida (Cl)
: 111 mEq/L
DIAGNOSA
Diagnosis kerja: STEMI inferior onset 2 harikillip I TIMI risk 2/14 Fungsional : KILLIP I Anatomi: Right Coronary Artery Etiologi:arterosklerosis
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
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) SR, QRS rate 69x, 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 15 April 2011 (CVCU, Pukul 19.00) 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 -,VESKesan: SR + STEMI inferior
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 -,VESKesan : 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 – Kesan : SR + STEMI inferior
TERIMA KASIH