Cardiovascular Case

ST Elevation Myocardial
Infarction (STEMI)
Ahmad Nur Islam (C111 06
012)
Medical Faculty of Hasanuddin University, Makassar 2010

Patients Identity
RM number
: 42 92 78
Name
: Mrs. DD
Age
: 59 years old
Address
: Jl. Toddopuli XI no.12
Date administered : 26th July 2010
Time administered : 22.34 am

History Taking
Chief complaint: chest pain
It occurred since 24 hours before
hospitalization, felt under the left chest
continuously, without radiated to his left arm
and jaw. The pain was not relieved by resting
or medication.
Shortness of breath (-), cough (-).
Nausea (+), vomiting (+) once, epigastric
pain (-), sweating (+).

History Taking (cont)

Fever (-), history of fever (-).
Defecation: normal
Micturition: normal
History of diseases and risk factors:
Smoking (-)
Hypertension (+)
Diabetes mellitus (-)
Heart disease in the past (-)

Physical Examination
General status
moderate illness/sufficient
weight/conscious
Vital sign
BP
HR
RR
T

:
:
:
:

140/90 mmHg
83 x/min
20 x/min
36,80C

Physical Examination
(cont)
Regional status
Head : anemia (-), icterus (-),
cyanosis(-)
Neck : JVP R-2 cmH2O
Thorax : breath sounds: vesicular
additional sounds: Rh: -/-, Wh: -/ Heart : heart sounds: S1-S2 pure,
regular,
murmur (-)
Abdomen : peristaltic (+), tympani,

Electrocardiography
(ECG)
(15-07-2010)
Sinus
rhythm, BP
83/min
ST elevation
I, aVL, V1
V6
(extensive
anterior wall
myocardial
infarction)

Chest X-Ray
Conclusion (15-07-2010):
Cardiomegaly with dilatatio et elongatio
aortae
Signs of pulmonary congestion and
oedema
Elevation of right diaphragm (CHF sign?)

Laboratory
Examination
Biochemical blood test (15-07-2010):

CK
: 224 (<190)
CKMB : 26 u/l
(<25)
RPG : 129 mg/dl
(140)
Ureum : 30 mg/dl (10-50)
Creatinin
: 1,6 mg/dl (<1,3)
GOT : 22 u/l
(<38)
GPT
: 18 u/l
(<41)
Tot Chol
: 249 mg/dl
(<200)
HDL : 40 mg/dl (>55)
LDL
: 155 mg/dl
(<130)
TG
: 268 mg/dl
(<200)

Laboratory
Examination
Routine blood test (15-07-2010):

WBC
RBC
HGB
HCT
PLT

:
:
:
:
:

12,17x103/ul
4,82x106/ul
12,5 g/dl
38,7%
353x103/ul

Electrolyte (15-07-2010):
Sodium
: 137 mmol/l
Potassium : 4,7 mmol/l
Chloride
: 108 mmol/l

(136-145)
(3,5-5,1)
(97-111)

Diagnosis
STEMI extensive anterior wall,
onset 4 hours, Killip I TIMI score 3/14
Hypertension grade I

Initial Management
Bed rest
O2 4 ltr/min
NaCl 0,9% 16 drops/min
Streptokinase 1,5 million unit/IV in
100 cc NaCl 0,9% (finish in 1 hour)
Petidin 25 mg IM
Monitoring vital sign

Planning
Serial ECG
(every half hour during and after
administration of thrombolytic)
Echocardiography

DISCUSSION

ST Elevation Myocardial
Infarction (STEMI)

Acute Coronary Syndrom

Acute coronary syndromes include:
Unstable Angina
Non ST-elevation MI (NSTEMI)
ST-elevation MI (STEMI)

Myocardial infarction rapid

development of myocardial necrosis by
a critical imbalance between oxygen
supply and demand of the myocardium

Diagnosis STEMI
Symptoms such as anginal chest pain,
dyspnoe, palpitation, diaphoresis.
ECG: ST segment elevation or new
onset LBBB
Enzymes: CKMB, Trop T and I

16

KILLIP
CLASSIFICATION
Killip class I includes individuals with no
clinical signs of heart failure.
Killip class II includes individuals with rales or
crackles in the lungs, an S3, and elevated
jugular venous pressure.
Killip class III describes individuals with frank
acute pulmonary edema.
Killip class IV describes individuals in
cardiogenic shock or hypotension (measured
as systolic BP<90 mmHg), and evidence of
peripheral vasoconstriction (oliguria, cyanosis
or sweating).

TIMI Risk Score for

STEMI
Historical
Age 65-74
>/= 75

2 points
3 points

DM/HTN or Angina

1 point

Exam
SBP < 100

3 points

HR > 100

2 points

Killip II-IV

2 points

Weight < 67 kg

1 point

Presentation
Anterior STE or
LBBB
Time to treatment >

1 point

Management
Supplemental Oxygen
Hypoxemia can occur in STEMI due to
ventilation perfusion mismatch
ABG should be obtained and if
saturation is normal, oxygen therapy is
not cost effective
If saturation is 90%, O2 should be given
at rates of 2-4 lits/min of 100%
concentration

Management
Antiplatelet agents
Aspirin

Integral part of initial management strategy

162 to 325 mg stat should be given as lower
doses take time to have their effect
Then continued indefinitely at a dose of 75 mg
to 162 mg
In patients for whom there is concern about
bleeding, lower doses of aspirin can be used

Clopidogrel 75 mg daily

Should depend on the judgment of the riskbenefit ratio for the individual patient

Management
Pain control
Morphine
Dose 4-8mg IV followed by 2-8 mg repeated at
intervals of 5-15 mins to achieve the desired
response or there is toxicity like hypotension,
respiratory depression or severe vomiting
Allays anxiety

Nitrates
Mechanism of action: coronary vasodilatation,
decreases ventricular preload
The only group of patients in whom these are
contraindicated are those having: inferior wall
AMI, suspected RV infarction, severe hypotension

Management
Beta blockers
Reduce pain, reduce need for analgesics,
reduce infarct size and reduce fatal
arrhythmias
Contraindications are: heart failure,
hypotension bradycardia and conduction
block
ACE inhibitors
Reduce mortality rates
Maximum benefit occurs in high risk patients
Reduces ventricular re-modeling after an

Management
Thrombolytic Agents
tPA
tPA Dose : 15mg IV bolus followed by 0.75mg/kg(max
50mg) over 30mins, followed by 0.5mg/kg(max 35mg) for
60 mins
Reteplase: not superior to tPA.
Tenecteplase: better than tPA in patients in whom lysis was
done after 4hrs from onset of symptoms

Streptokinase
Streptokinase Dose : 1.5MU in 30-60 mins
Antigenic and cause allergic reactions
May be ineffective in patients who have received strepto in
the past 1 yr

Thrombolytic Agents
Indication
MI and ST segment elevation greater than 0.1mV in 2 contiguous ECG leads, or
new onset LBBB, who present less than 12 hours but not more than 24 hours
after symptom onset

Contraindications

Any prior ICH Structural cerebral vascular lesion

Malignant intracranial neoplasm
Ischemic stroke within 3mo except acute ischemic stroke within 3hrs
Suspected aortic dissection
Active bleeding or bleeding diathesis
Significant closed head or facial trauma within 3 months

Choice of therapy
Choice of therapy For patients who present in <4hrs, choice is tPA, as the
speed of reperfusion is important
For patients who come between 4-12 hrs, strepto and tPA are equivalent
options
Of note, those patients having increased rise of ICH (like elderly with inf. AMI,

Management
Antithrombin therapy
IV UHF bolus at 60U/kg to a maximum of
4000U followed by initial infusion of
12U/kg/hr to a max of 1000U/hr given for
48 hours has established efficacy in
patients receiving thrombolytic therapy
Prolonged administration may be
beneficial.
Other drugs: hirudin, bivalirudin, LMWH,
fondaparinux

Management
Lipid Management
Post MI patients with LDL > 100 mg/dl
are recommended to be on drug therapy
to try to lower levels to <100 mg/dl
Recent data indicate that all MI patients
should be on statin therapy, regardless
of lipid levels or diet

Management
Surgical Revascularization
PTCA (percutaneous transluminal coronary
angioplasty)
CABG (coronary artery bypass grafting)

THANK YOU