Cardiology Department

Faculty of Medicine
Hasanuddin University

Case Report
2016

STEMI
Warren Lie
C11112007
Supervisor:
dr. Pendrik Tandean, Sp.PD-KKV, FINASIM

PATIENT IDENTITY
Name
: Mr SD
Age
: 43 y, 2 mo, 27d
Sex
: Male
ID
: 751291
Date of admission : 27 MAR 2016

HISTORY
Chief complaint: chest pain
Further anamnesis:
First time felt 3 days ago intermittently with
duration of + 15 minutes, resolve with rest.
Squeezing and crushing in quality, radiates to
both arms, back, and left jaw. Eight hours before
admission pain becomes persistent. NPRS 9.
Diaphoresis (+), nausea(+), vomiting (-),
fever(-), dyspnea (+), urination and defecation
normal.
Pain on both legs (+).

HISTORY
Past Medical History:
No known history of hypertension
No known history of DM
History of dyslipidemia (hypercholesterolemia)
No history of heart disease or stroke
History of gout arthritis
No history of cigarette smoking
No family history of heart disease or stroke

PHYSICAL EXAMINATION
General condition:
moderate illness/ normal weight/ conscious
BW: 53 kg, BH: 160 cm, BMI: 20.5 kg/m2
Vital Sign
BP: 100/70 mmHg
R : 20x/min
HR: 80x/min, regular
T : 36.5 oC
Head: pupil round equal size 2.5mm anemia (-),
jaundice (-),
cyanosis (-)
Neck: JVP R+2 cmH20 (30o)

PHYSICAL EXAMINATION
CHEST EXAMINATION
Inspection : symmetrical, no scar, ictus cordis
not visible
Palpation : no mass/tenderness, apex not
palpable
Percussion : normal heart size, liver border ICS 6
Auscultation :
Lung : vesicular breath sound
Rh -/+ (basal) Wh -/Heart : S1 S2 regular, murmur (-)

PHYSICAL EXAMINATION
ABDOMINAL EXAMINATION
Inspection : Flat, follow breath movement
Auscultation : Peristaltic sound (+), normal
Palpation : No mass/tenderness, Liver and spleen are
palpable
Percussion : Tympani (+), no ascites

EXTREMITIES

Hands and feet well perfused

Pretibial edema -/Dorsum pedis edema -/Cyanosis (-), finger clubbing (-)
Tofus +++

not

ELECTROCARDIOGRAM

ECG Interpretation

Rhythm : Sinus Rhythm

Regularity
: Regular
HR / QRS rate : 66 bpm
Axis
: Normoaxis
P wave
: 0.08 s, 0.1 mV
PR interval
: 0.12 s
QRS complex : duration 0.12 s, poor R wave progression
ST segment : elevation on lead V1-V4
T wave: inversion on lead V1-V5, II, III, aVF
Conclusion : Anteroseptal MI

Lab Findings

PARAMETER

RESULT

NORMAL
VALUE

UNIT

WBC

12.42

4.0 10.0

10^3 u/L

Neutrophil

76.5

52.0 75.0

RBC

5.10

4.0 6.0

10^6 u/L

HGB

13.6

13.0 17.0

g/dL

HCT

43.0

40.0 54.0

PLT

321

150 - 500

10^3 u/L

Ureum

29

10 - 50

mg/dL

Creatinine

1.07

<1,3

mg/dL

SGOT

231

<38

U/L

SGPT

48

<41

U/L

Glucose

111

<140

mg/dL

CK

3743

<190

U/L

CK-MB

211.6

<25

U/L

Troponin I

>10.0

<0.01

ng/mL

Sodium

146

136-145

mmol/L

Potassium

4.1

3.5-5.1

mmol/L

Chloride

113

97-111

mmol/L

STEMI anteroseptal Killip II onset 8 h

Congestive heart failure NYHA III
Gout arthritis acute exacerbation

Therapy
Oxygen 2-4 L/min
NaCl 0.9% 500cc/24h/IV
Thrombolysis:
Alteplase bolus 15mg followed by 50mg IV (30 min) and 35mg IV (1 hour)
Antithrombotic:
Aspirin 80mg/24h/oral
Clopidogrel 75mg/24h/oral
Fondaparinux 2.5mg/24h/SC
Diuretic: furosemid 40mg/12h/oral
HMG-CoA reductase inhibitor: atorvastatin 40mg/24h/oral
ACE-inhibitor: captopril 12.5mg/8h/oral
Nitrates: ISDN 1 mg/1h/SL
Sedative: alprazolam 0.5mg/24h/oral
GOUT: colchicine 0.5mg/24h/oral

Planning
Echocardiography
Angiography
Risk factor management

STEMI

DISCUSSION

ACUTE CORONARY
SYNDROME

Acute coronary
syndrome (ACS) refers
to a spectrum of
clinical presentations
ranging from those for
ST-segment
elevation myocardial
infarction (STEMI)
nonST-segment
elevation myocardial
infarction (NSTEMI)
unstable angina
pectoris

Acute Coronary
Syndrome

ETIOLOGY
Mechanism:
Coronary plaque rupture (95%)
lead to partial or total coronary occlusion
Coronary spasm
Prinzmetal angina (transient ST elevation)
Myocardial infarction (if the ischemic period is too
long)
Coronary embolism

ACUTE CORONARY
SYNDROME
UA/NSTEMI
Non-occlusive
thrombus
No ST segment
elevation as
transmural infarction is
not seen
NSTEMI vs unstable
angina pectoris
cardiac enzyme

STEMI
Occlusive thrombus
Entire thickness of the
myocardium has
undergone necrosis,
resulting in STsegment elevation

RISK FACTOR
NON- MODIFIABLE
Gender
Men > women
Age
Men, increased risk after age 55
Women, increased risk after
age 65
Family History

Heart disease diagnosed before

age 55 in father or brother

MODIFIABLE
Hypertension
Diabetes Mellitus
Dyslipidemia
Obesity
Lack of physical
activity
Diet (high fat and
high carbohydrate)

Heart disease diagnosed before

Cigarette Smoking

age 65 in mother or sister

Stress

PATOPHYSIOLOGY
Plaque
disruption

Platelet

GP IIb/IIIa

Coagulatio
n cascade

Agonist
(collagen,
ADP,
epinephrine
)

TX A2

DIAGNOSIS
Chest pain

Sympto
m
Workin
g
diagnos
is

Acute
coronary
syndrome

Non ST
elevation

ST
elevation

ECG
Biomarker

Biochemist
ry

Final
diagnos
is

(+)

STEMI

Non STEMI

(-)

Unstable
angina

The chest discomfort

may also be
described as a dull
pain ,pressure,
squeezing or
crushing sensation
or burning sensation

Substernal chest
pain / chest
discomfort
radiated to the
left arm,
shoulder, neck,
jaw

Clinica
l
featur
es

Duration of
chest pain
> 20
minutes

Not fully
relieved by rest
or
nitroglycerine

WORKING DIAGNOSIS
(ACS )
Ischemic symptoms
Prolonged chest pain (usually >20 mins) constricting,
crushing, squeezing. Usually retrosternal, radiating to left
chest, left arm, can be epigastric
Dyspnea
Diaphoresis
Palpitations
Nausea/vomiting
Light headedness
Autonomic nervous system hyperactivity

Rise of serum
cardiac
biomarkers

Characteri
stic
symptoms

WHO
Diagnos
tic
Criteria

Changes in
serial ECG
tracings

HOW TO DIAGNOSE?

ECG
STEMI

NSTEMI

ECG EVOLUTION (AMI)

Hyperacute Phase
Non Specific ST-Elevation
T taller and wider

Complete Evolution
Specific ST-Elevation
T inversion
Pathologic Q

Old Infarct
Pathologic Q
ST segment isoelectric
T normal or inverted

Location of myocardial infarction by EKG changes

No

Location AMI

ECG

Anterior

ST segment elevation and / or Q waves in V3-V4

Anteroseptal

ST segment elevation and / or Q waves in V1-V4

Anterolateral

ST segment elevation and / or Q waves in V1-V6 and I and

aVL

Lateral

ST segment elevation and / or Q waves in V5-V6 and

T wave inversion / ST elevation / Q-wave in I and aVL

Inferolateral

ST segment elevation and / or Q waves in II, III, aVF, and

V5-V6 (sometimes I and aVL)

Inferior

ST segment elevation and / or Q waves in II, III, and aVF

Inferoseptal

ST segment elevation and / or Q waves in II, III, aVF, V1-V3

True posterior

High R wave in V1-V2 with ST segment depression in V1-V3.

Upright T wave in V1-V2

BIOMARKERS

BIOMARKERS
Biochemical marker for detection of myocardial
necrosis
Normal value

First rise
after AMI

Peak after
AMI

Return to
normal

CK-MB

< 5.0 ng/ml

4h

24 h

72 h

Myoglobin

< 82 ng/ml

2h

6-8 h

24 h

4h

24 - 48 h

5 21
days

3-4 h

24 36 h

5 14
days

Troponin T Negative
Troponin I

Detection Limit = 0.5

ng/ml
Abnormal > 2.0 ng/ml
Borderline - Not
detected

Therapy
Oxygen
Control of Discomfort
Nitrates
Morphine 2-4mg/5mins/IV
Beta-blocker
Limitation of Infarct Size
Primary PCI
Fibrinolysis
Sedation
Antithrombotic
RAAS inhibitor

M
O
N
A
B
A
H

TREATMENT

PROGNOSIS
KILLIP CLASSIFICATION

Class

Description

Mortality Rate (%)

No clinical signs of heart

failure
Rales or crackles in the
lungs, an S3, and elevated
jugular venous pressure
Acute pulmonary edema
Cardiogenic shock or
hypotension (systolic BP
< 90 mmHg), and
evidence of peripheral
vasoconstriction

II

III
IV

17

30 - 40
60 80

TIMI Risk Score for

STEMI
Risk Score
Odds of death by

TIMI Risk Score for STEMI

Historical
Age 65-74
2 points
>/= 75
3 points
DM/HTN or
1 point
Angina
Exam
SBP < 100
3 points
HR > 100
2 points
Killip II-IV
2 points
Weight < 67 kg
1 point
Presentation
Anterior STE or
1 point
LBBB
Delay treatment
1 point
> 4 hrs
Risk Score =
(0-14)
Total

30D*
0
0.1 (0.1-0.2)
1
0.3 (0.2-0.3)
2
0.4 (0.3-0.5)
3
0.7 (0.6-0.9)
4
1.2 (1.0-1.5)
5
2.2 (1.9-2.6)
6
3.0 (2.5-3.6)
7
4.8 (3.8-6.1)
8
5.8 (4.2-7.8)
>8
8.8 (6.3-12)
* referenced to average mortality
(95% confidence intervals)

DM, diabetes mellitus; HTN, hypertension; SBP, systolic blood pressure; HR,
heart rate; STE, ST elevation; LBBB, left bundle branch block; and rx, treatment.

COMPLICATION

Ventricular dysfunction
Congestive heart failure
Cardiogenic shock
Arrhythmia
Thromboembolism
LV aneurysm/rupture