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Case

Report
ST ELEVATION MYOCARDIAL INFARCTION
WHOLE ANTERO SEPTAL >12 HOURS
KILLIP I

Presented by:
L.M. Dila Pramashari
Supervisor:
dr. Pendrik Tandean, Sp.PD-KKV, FINASIM

PATIENT IDENTITY

Name

: Mr. M

Age

: 56 years old

Address

: Lingkungan Tompobalang

Occupation

: not working

MR

: 79766

Date of Admission : Nopember, 19, 2016

HISTORY TAKING

Chief complaint : Chest pain

Present Illness History :

chest pain felt since 3 days before admission while the


patient is resting.

Described as compressed pain that felt through to the


back and radiating to left arm, intermittently, duration
of pain more than 20 minutes.

Pain accompanied with cold sweats.

There are no nausea and vomiting, no dypsnea on


effort, there is no paroxysmal nocturnal dypsnea

HISTORY TAKING

Past Illness History :

History of hypertension (+) since 10 years ago and uncontrolled

History of Diabetes Mellitus (-)

History of heart disease (-)

History of heart disease in family (-)

History of chest pain before (-)

Gout (+)

Personal Life History :

No history of alcohol consumption

There is history of smoking for the past 20 years ago, 6


cigarettes per day

RISK FACTOR
Modifiable:
Hypertension, since 10 years a go, medicine control
irregularly
Smoking, 6 cigarettes per day
Non modifiable:
Age (56 y.o)

PHYSICAL EXAMINATION

General Status

Moderate illness / normoweight / Composmentis

Weight

: 55 kg

Height

: 160 cm

BMI : 21,48 kg/m2

Vital Status

Blood pressure

:150/90 mmHg

Heart rate

: 88 bpm

Respiratory rate : 20 rpm

Temperature : 37,2 oC

PHYSICAL EXAMINATION

Head

: anemic (-) icteric (-)

Neck

: JVP R+2 cmH2O, at 300 supine position

Lung

Inspection

: symmetry left=right

Palpation
vocal

: mass (-), no tenderness, normal


fremity

Percussion

: sonor

Auscultation

: vesicular, ronchi -/-, wheezing -/-

PHYSICAL EXAMINATION

Cor

Inspection

: ictus cordis not visible

Palpation

: ictus cordis not palpable, thrill (-)

Percussion

Upper border 2nd ICS sinistra


Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea axillaris anterior sinistra

Auscultation : heart sound I/II pure, regular, murmur (-)

PHYSICAL EXAMINATION

Abdomen :

Inspection

Auscultation : peristaltic (+), normal

Palpation

: liver and spleen not palpable

Percussion

: tympani

Extremities :

Edema (-)

: flat, follows breath movement

ELECTROCARDIOGRAPHY

Sinus rhythm
Heart rate : 94x/minutes
Duration QRS
: 0,08 s
Axis : normoaxis
Pathological Q in V1-V3
P Wave
: 0,08 s
ST segment : ST elevation on lead V1, V2, V3
PR interval : 0,16 s
R Wave : Poor R Wave Progression in V1-V3
Conclusion :
Sinus rhythm, HR 94 bpm, normoaxis, ANTEROSEPTAL ST elevation myocardial infarction

LABORATORY RESULTS
TEST

RESULT

NORMAL VALUE

WBC

10,0 x 103/uL

4.0 10.0 x 103

RBC

4,02 x 106/uL

4.0 6.0 x 106

HGB

12,0g/dL

HCT

TEST

RESULT

NORMAL
VALUE

GDS

116 mg/dL

<140

SGOT

27 u/L

<38

12 18

SGPT

30 u/L

<41

37,6%

37 48

Ureum

14

10-50

PLT

217 x 103/uL

150 400 x 103

Kreatinin

0,7

0,5-1,2

PT

10,2

10 - 14

Troponin I

>10,0

<0,05

APTT

26,9

22,0 - 30,0

CK

983,00

<190

T. Chol

102

200

CKMB

71,0

<25

LDL

98

<130

Na

143

136 - 145

HDL

45

>55

3,5

3,5 - 5,1

Trig

91

200

Cl

109

97 - 111

Uric Acid

9,0

3,4-7,0

CHEST X-RAY

- CTI 0,56
- Aorta dilatation
- Normal bronchovascular
marking on both of parahilar
- Normal sinus and diaphragm
Result :
Cardiomegaly (CTI index : 0.56)
with aortae dilatation

ECHO CARDIOGRAPHY

Sistolik disfungtion of left


ventrikel
Left ventikel hipertrophy :
positive consentric
EF 46 %
Akinetic of mid basal
anterior, apicoanterior.
Hypokinetic of mid basal
anterolateral,anteroseptal,
apicoseptal..

Conclusion:

Sistolik disfungtion of left


ventrikel

Left ventikel hipertrophy :


positive consentric

Segmental Hipokinetik

WORKING DIAGNOSIS

ST Elevation Myocardial Infarction (STEMI) Whole Anterior onset > 24 hours,


KILLIP I
Hipertension Grade I
Hiperuricemia

TREATMENT
O2 4 lpm via nasal cannula
IVFD NaCl 0,9% 500 cc/24 hours
Aspilet 160 mg (loading dose), maintenance 1x80 mg
tab
Clopidogrel 300 mg(loading dose), maintenance 1x75
mg tab
Cedocard 0,5 mg/24 hours/SP
Captopril 6,25 mg/ 8 hours/ oral
Bisoprolol 1,25 mg/ 24 hours/ oral
Arixtra 2,5mg /24 hours/ subcutan
Atorvastatin 40 mg/24 hours/oral
Allopurinol 100 mg/24 hours/oral

DISCUSSION

INTRODUCTION
Acute coronary syndromes (ACS) is a
term for situations where the blood
supplied to the heart muscle is suddenly
blocked.
ST-Elevation Myocardial Infarction
There is a transmural infarction of the
myocardium. Entire thickness of the
myocardium has undergone necrosis.
Usually occurs when blood flow of
artery coronary suddenly decreased
after occlusive thrombus on
atherosclerotic plaque.
Coronary plaques tend to rupture if it
has a thin fibrous cap and a lipid-rich
core.

RISK FACTORS

Modifiable
Smoking
Hypertension
Diabetes mellitus
Hypercholesterolemia
Obesity
Psychosocial stress
Lack of physical activity

NonModifiable
Gender & Age
Men > 45 years old
Women > 55 years old

Family history
Heart
Heart disease
disease in
in biological
biological
brother
or
father
brother or father >
> 55
55 years
years
old
old
Heart
Heart disease
disease in
in biological
biological
sister
or
mother
>
sister or mother > 65
65 years
years
old
old

CLINICAL FEATURES OF ACS


Unstable Angina
Symptom :
Crescendo, rest
new onset angina.
Non Occlusive
Thrombus
Non Specific ECG
Normal Cardiac
Enzymes

NSTEMI

STEMI

Prolonged crushing chest pain, more severe,


wider radiation
Non-Occlusive
thrombus /partial
occlusive
thrombus
ST depression, T
wave Inversion on
ECG
Elevated Cardiac
Enzymes

Complete
Thrombus
Occlusion
ST Elevations on
ECG or new
LBBB
Elevated Cardiac
Enzymes

CLINICAL MANIFESTATION
Characteristic pain : severe, persistent,
typically substernal
Sympathetic effect : Diaphoresis, cool
and clammy skin
Parasympathetic (vagal effect) :
Nausea, vomiting, weakness
Inflammatory response : mild fever

Pathophysiology

Pathophysiology

ECG CHANGES

CARDIAC BIOMARKERS

DIAGNOSIS

GOAL OF TREATMENT

Relieve pain

Hemodynamic
stabilization

Myocardial
reperfusion

Prevent the
complication

MANAGEMENT

COMPLICATIONS

PROGNOSIS
KILLIP CLASSIFICATION
CLASS

DESCRIPTION

MORTALITY RATE
(%)

No clinical signs of heart


failure

II

Rales or crackles in the lungs,


an S3, and elevated jugular
venous pressure

III

Acute pulmonary edema

30 - 40

IV

Cardiogenic shock or
hypotension (systolic BP < 90
mmHg), and evidence of
peripheral vasoconstriction

60 80

6
17

Thank You