Case Report A F I F T Y- F O U R Y E A R S O L D M A L E PAT I E N T

WITH CARDIOVERSION EC HEMODYNAMIC

I N S TA B I L I T Y, V E N T R I C U L A R TA C H Y C A R D I A
WITH STEMI ANTERIOR EXTENSIVE IN CUT
M E U T I A G E N E R A L H O S P I TA L . W H AT S H O U L D
WE DO NEXT

Composed by:
1. S a k i l a E r s a P u t r i H u t a s u h u t , S . K e d ( 2 1 0 6 111 0 0 6 )
2. Adinda Fahira D. Mtd, S.Ked ( 2 1 0 6 111 0 1 7 )
3. Richy Dara Perdana, S.Ked ( 2 1 0 6 111 0 4 2 )
4. Melina Handayani, S.Ked
( 2 1 0 6 111 0 4 1 )
5. Muhammad Al Farisi, S.Ked ( 2 1 0 6 111 0 1 9 )

DEPARTEMENT OF CARDIOLOGY
MEDICAL FACULTY OF MALIKUSSALEH UNIVERSITY
CUT MEUTIA GENERAL HOSPITAL
NORTH ACEH Preceptor:
2022 dr. Yuri Savitri, M. Ked (Cardio), Sp. JP, FIHA
 PRELIMINAR
1 Y
  Ventricular tachycardia (VT) is a type of abnormal heart rhythm or
arrhytmia. It occurs when the lower chamber of the heart, called
the ventricles, beats too fast. Usually occur at the rate of 100–250
complexes a minute.
 VT that remains for less than 30‘s or does not require immediate
termination is known as non-sustained VT and that requiring
immediate termination or lasting more than 30’s is sustained VT.
 QRS contours on electrocardiogram during the VT can be
unchanging (monomorphic) or can vary randomly (polymorphic).

3
Profile of patients presenting with sustained ventricular tachycardia in a tertiary care center. Indian Heart Journal. 2018
  The symptomatology and hemodynamic consequence of VT depends on its
rate and underlying heart disease
 Myocardial ischemia and infarction are significant factors of ventricular
tachycardia (VT). Additional risk factors include mitral valve disease, heart
failure, electrolyte imbalances such as hypokalaemia, drug intoxicant from
digoxin, pararhyme effects of some antiarrhythmics
 Prompt and judicious treatment is required to prevent hemodynamic collapse
and death. The options include: Cardioversion (usually electrical and
occasionally chemical), Cardiopulmonary resuscitation, Antiarrhythmic drug
therapy, Pacing/intracardiac defibrillator, and Ablation.

4
Profile of patients presenting with sustained ventricular tachycardia in a tertiary care center. Indian Heart Journal. 2018
 CASE
2 REPORT
 A 54 years old male patient, domiciled Tanah Jambo Aye, North Aceh, the patient was
brought from dr. Yuri’s clinic and admitted to emergency department of Cut Mutia
hospital at 21.00 pm on Mei 20th, 2022. He was experienced stabbing chest pain,
dyspnea, and sudden onset of palpitations. Chest pain was felt since 4 days ago and
getting worst 1 day before come to dr. Yuri’s clinic. The pain was radiated into the back
and left arm. And the pain doesnt get better with rest.
The patient has a history of diabetes mellitus, high blood pressure were denied.
Patients who have smoked heavily in the past, up to 3 packs per day, but have not
smoked in over a year.

6
 His consciousness was clear on arrival and his vital signs included a body
temperature of 36.6°C, a pulse rate of 124 beats per minute, a respiratory rate of
22 breaths per minute, and blood pressure of 130/90 mmHg. Chest examination
show breath sounds were vesicular.

Laboratory on Mei 17th 2022 showed hemoglobin of 16,24 g/dl, hematocrit of

44,32 %, leucosytes of 14,48 thousand/uL, platelets of  247 thousand/uL, blood
glucose 407 mg/dl. And then result of  laboratory on Mei 18th 2022, there were
total cholesterol of 202 mg/dl, HDL of 54 mg/dl, LDL 128 mg/dl, Trigliserida of 185
mg/dl and blood glucose 269 mg/dl. On Mei 19th showed troponin of 3,72 ng/ml.

7
The first ECG on Mei 17th 2022 showed A 12-lead ECG showed arrhytmia,  heart
rate was 140 bpm, wide QRS complex 0,16 second and have the same shape and
amplitude in all lead. The conclusion was  monomorphic ventricular tachycardia.

8
The second ECG on Mei 18th 2022 (after DC shock) showed that sinus
rhythm, heart rate was 93 bpm, normoaxis, and ST segment elevation in
lead I, AVL, V1-V6. The conclusion was anterior ekstensive STEMI.

9
The third ECG on mei 19th 2022 (before transport to bigger hospital) showed
arrhytmia, heart rate was 98 bpm, normoaxis, and ST segment elevation in
lead I, AVL, V1-V6. The conclusion was anterior ekstensive STEMI.

10
 COR
- CTR <50%
- Aortic segment was normal
- Pulmonary artery was not prominent
- Heart waist (+)
- Apex was normal

PULMO
- Bronchovascular pattern was normal
- Right and left costrophenic angle are sharp
RESULT
- Cor and Pulmo was normal

11
Echocardiographic examination showed MS
severe, normal valves, diastolic dysfunction,
anteroseptal hypokinetic, Tricuspid Annular
Plane Systolic Excursion (TAPSE) 24, with
EF was 51%.

12
 The patient was given treatment in Cut Mutia General Hospital. The patient comes
to the emergency department RSUCM, then the fisrt treatment is with cardioversion DC
shock 200 joules with injection of ventolin 1 amp, injection of midazolam 1 amp, and
injection of epinefrin 1 amp. Then follow-up treatment with injection of furosemide 2
amp/8h, injection of fondaparinx (arixtra) /24h, aspirin (Aptor) 1x100 mg, CPG 1x75
mg, atorvastatin 1x40 mg, lansoprazole 2x0 mg, isoptolol (concor) 1x2,5 mg, and
novorapid insulin 20-0-20.

13
14
3 DISCUSSION
  Ventricular tachycardia (VT), also known as wide-complex
tachycardia or V-tach, refers to the rapid ventricular contraction and
the ventricular rate frequency exceeding 100 beats/min. Sometimes
up to 250 beats/min.
 When the heartbeat is this so fast that it's not able to circulate
adequate oxygenated blood to the rest of the body.
 About 7% of patients with cardiac arrest are diagnosed with VT. VT
is an extremely unstable rhythm because it's of unpredictable.

16
Tachycardia Electrical Storm in Structural Heart Disease. Journal of The Saudi. 2019
Patient was admitted to hospital with complains of stabbing chest pain,
dyspnea, and sudden onset of palpitations. The pain was radiated into
the back and left arm. And the pain doesnt get better with rest. The
patient has a history of diabetes mellitus, high blood pressure were
denied. Patients who have smoked heavily in the past, up to 3 packs per
day, but have not smoked in over a year.

17
  The major symptoms of VT are palpitations, syncope, and in extreme cases
sudden cardiac death. Some patients also complain of chest pain and shortness of
breath. In general, VT is a hemodynamically unstable rhythm, although sometimes
it can be tolerated for a few minutes to hours, especially in presence of a left
ventricular assist device
 In this case the patient also complained of chest pain. Chest pain or discomfort is
the most common symptom in acute coronary syndrome. This pain often described
as aching, pressure, tightness or burning. Pain spreading from the chest to the
shoulders, arms, upper abdomen, back, neck or jaw

18
Perki. Pedoman Tata laksana Sindrom Koroner Akut. 4th ed. Inaheart; 2018
 o A normal heartbeat begins with an electrical impulse
o Most of the patients with VT
from the sinus node, a small area in the heart’s right
complained chest pain that's
atrium (right upper chamber). Ventricular tachycardia is
basically because the heart itself
isn't getting enough oxygenated a type of abnormal heart rhythm (arrhythmia) caused by
blood. VT can lead to angina, heart irregular electrical signals in the lower chambers of the
failure or significant reduction in heart (ventricles). This condition causes the heart beats
organ perfusion. faster, usually 100 or more beats a minute.
o Another common symptom is feeling o When the heart beats too fast, it may not be able to
of palpitations, which is the pump enough blood to the rest of the body. So the
sensation that the heart is beating organs and tissues may not get enough oxygen. Signs
out of the chest wall feels like a heart and symptoms that occur during an episode of VT are
beating against chest wall like a
due to a lack of oxygen and may include: chest pain
drum.
(angina), pounding heartbeat (palpitations), dizziness,
lightheadedness, and shortness of breath.

19
Ventricular tachycardia. The Southwest Respiratory and Critical Care Chronicles. 2017
 Physical examination before treatment was obtained the
patient looked weak, BP: 70/60 mmHg, HR: 143x/minute,
RR: 24x/minute, SpO2: 94%, T: 36,6 °C. Chest examination
show breath sounds were vesicular. In this case on physical
examination showing hypotension, tachycardia and dyspnea.
These are are sign of of hemodynamic unstable. These are are
sign of of hemodynamic unstable.

20
In this case on laboratory examination before treatment on May 18th, 2022
the results of cardiac troponin: <0.1 ng/mL. Serum cardiac biomarkers
(creatine kinase [CK], CK-MB, cardiac specific troponins, myoglobin) are useful
for confirming the diagnosis of MI and estimating infarct size

Laboratory examination after treatment on May 19th 2022 results increased

cardiac troponin: 3.72 ng/mL. That an increase in the concentration of cardiac
troponins in biological fluids, in particular in blood serum, indicates reversible or
irreversible damage to cardiomyocytes, but does not explain the etiopathogenesis of
such damage, which may occur in a number of other pathological processes not
associated with myocardial infarction. For patients with ST-segment elevation, the
diagnosis of STEMI is secure; initiation of reperfusion therapy should not be delayed
while awaiting the results of a cardiac biomarker assay

Pedoman Tata laksana Sindrom Koroner Akut. 4th ed. Inaheart; 2018
The Main Causes And Mechanisms Of Increase In Cardiac Troponin Concentrations Other Than Acute Myocardial Infarction (Part 1): 21
Physical Exertion, Inflammatory Heart Disease, Pulmonary Embolism, Renal Failure, Sepsis. Vasc Health Risk Manag. 2021
In this case on laboratory examination of the blood chemistry on May 18th, 2022 the
results of blood chemistry: Total kolesterol 202 mg/dl, HDL 54 mg/dl, LDL 128 mg/dl,
Triglycerides 185 mg/dl, Fasting glucose 269 mg/dl.
 In addition to its association with atherosclerotic plaques, high cholesterol has been
shown to cause changes in membrane properties, including the function of hormone
receptors, ion channels and pumps. These effects are mediated through direct
interactions between cholesterol and the membrane proteins, through changes in
membrane fluidity and/or an association with lipid rafts. Cholesterol-lowering therapy,
therefore, may prove an effective method for the treatment of cardiac arrhythmias.

 Patients with elevated serum glucose levels had a 40–70% higher odds of developing
any VT or early VT compared with patients with lower serum glucose levels in those
with and without a history of diabetes

22
 Electrocardiagram in the first time conclusion was monomorphic
ventricular tachycardia. From the second and third electrocardiography
means acute anterior extensive ST-elevation myocardial infaction
(STEMI) is defined by ST-elevation (STE) in leads I, AVL, V1-V6. STE in
precordial lead means associated with infarct in Ramus
interventricularis anterior artery coronaria sinistra, Occlusion in artery
coronaria sinistra will cause infarct anterolateral, it can been seen in
lead I,AVL and V1-V6.

23
Satu-Satunya Buku EKG yang Anda Perlukan, Malcolm S. Thaler, 2016, Edisi 8. Jakarta
 The result by x-ray findings showed that
 Echocardiography is the available modality widely and
cor was normal.
cheaply and has great benefits in establishing the diagnosis
of ventricular infarction, as well as evaluating ventricular
shape, size and function. An echocardiogram estimates
ejection fraction, a measure of how efficiently your heart is
Echocardiographic examination
pumping blood and oxygen to your organs
showed MS severe, normal valves,
 A measured TAPSE of 1.7 centimeters (cm) or greater was
diastolic dysfunction, anteroseptal
hypokinetic, Tricuspid Annular accepted as normal per the recommendations from the
Plane Systolic Excursion (TAPSE) American Society of Echocardiography (ASE). The greater
24, with EF was 51%. the displacement, the better is right ventricular function a
value less than 16 mm is considered abnormal
 A normal ejection fraction is between 50% and 70%, which
means the left ventricle pumps out between 50% and 70% of
its total volume
Visual Estimation of Tricuspid Annular Plane Systolic Excursion By Emergency Medicine
Clinicians. West J Emerg Med. 2020 24
What is an Echocardiogram (and How do I Interpretation The Report). GoodRx Health; 2021
 • When wide QRS tachycardia is complicated by unstable vital signs,
electrical cardioversion should be performed immediately. Treatment
of ventricular tachycardia depends on the clinical condition of the
patient, conscious patient with intermittent episodes of VT
management should be by using drugs, conscious patient with
ongoing VT triggered (synchronized) using direct current (DC)
cardioversion under general anaesthesia, disturbed and unconscious
patient with ongoing VT triggered (synchronized) with DC
cardioversion according to guidelines ACLS

AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the 25
Prevention of Sudden Cardiac Death. Vol. 138. 2017
 • If the hemodynamic state is stable, termination of VT is carried
out by administering intravenous drugs such as amiodarone,
lidocaine, and procainamide. Amiodarone and procainamide are
superior to lidocaine. Amiodarone can given in a loading dose of
15 mg/min given in 10 minutes and followed by a continuous
infusion of 1 mg/minute for 6 hours, and a dose of maintenance
0.5 mg/minute for the next 18 hours. If it fails With medication,
electrical cardioversion is performed, which can be started at low
energy (10 J and 50 J).

ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death the Task Force for the
Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death of the European Society of Cardiology (ESC) 26
Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC). Eur Heart J. 2015
 • This patient also diagnosed with • Primary PCI is superior to
STEMI. PCI is a strategy for fibrinolysis in reducing mortality,
reperfusion in STEMI. Primary PCI reinfarction, or stroke. However,
is the preferred reperfusion in some circumstances, primary
strategy in patients with STEMI PCI is not an immediate option
within 12 h of symptom onset, and fibrinolysis could be initiated
provided it can be performed expeditiously
expeditiously 120 min from STEMI
diagnosis.

27
ESC Guidelines For The Management of Acute Myocardial Infarction in Patients Presenting With ST-Segment Elevation. Eur Heart J. 2018
TERIMA KASIH

28