JULY 2017

CASE REPORT:
STEMI ANTEROSEPTAL WALL
ONSET 4 HOURS, KILLIP 1

Presented by:

Aulia Azizah Kosman C111 13 101

Supervisor:
dr. Pendrik Tandean, SpPD-KKV,
FINASIM
PATIENT IDENTITY

Name : Mr. MT
Age : 55 years old
Gender : Male
Address : Tinanggea
Medical Record : 805671
Admitted : June 27th, 2017
HISTORY TAKING

Chief complaint : chest pain

Present Illness History :
Suffered since 4 hours before admission

Described as retrosternal pain ,compressed pain and

radiating to left arm, persistent, duration of pain >30
minutes, accompanied with cold sweat. The intensity is not
influenced by activity.
There were no shortness of breath, DOE, PND and
ortopnue
No history of fever and cough

No nausea and vomiting

HISTORY TAKING

Past Illness History :

No history of chest pain
History of hypertension was denied
History of Diabetes Mellitus was denied
Family history with cardiac failure present in his older brother

Lifestyle History:
History of smoking (+), since 20 years ago, 1 packs/day
RISK FACTOR

Modified Risk Factor

Smoking

Non-modified risk factor:

Gender : Male
 Physical Examination

General Moderate illness/well

Nourished/composmentis
status GCS E4M6V5

Blood pressure 130/90 mmHg

Vital status

Heart rate 81 bpm
Respiratory rate 21 tpm
Temperature 36,7 oC

Head and anemic (-), Icteric (-/-)

Neck JVP R+3 cm H2O

 Thorax

inspection Normochest, Symmetry left = right

Mass (-), tenderness (-), cracless (-),

palpation normal vocal fremitus

sonor, lung liver border in ICS VI right

percussion anterior.

auscultation Vesicular, ronchi -/-, wheezing -/-

 Cor
inspection Ictus cordis not visible

palpation ictus cordis not palpable, thrill (-)

Upper border 2nd ICS sinistra, Right border 4th ICS

percussion linea parasternalis dextra, Left border 5th ICS linea
axillaris anterior sinistra

Heart sound I/II reguler, murmur (-

auscultation )
 Abdomen
inspection Flat, follow breath movement

auscultation Peristaltic (+) normal

Mass (-), Hepar and lien not

palpation palpable

percussion Ascites (-)

Extremities examination

Pretibial edema -/-

cyanosis (-)
ELECTROCARDIOGRAPHY
Rhythm : sinus
rhytm
Heart Rate :
75bpm
Regularity : reguler
PR interval: 0.16 sec
Axis : normoaxis
Duration of QRS :
0.08sec
ST segment :
elevation
in V1-V3

Conclusion:
Sinus rhytm,
HR 78x/mnt,
normoaxis,
STEMI
anteroseptal
 Laboratory Finding

TEST RESULT NORMAL VALUE TEST RESULT NORMAL VALUE

WBC 11,22x 103/uL 4.0 11.0 x 103 SGOT 43 u/L <38
RBC 5,18x 106/uL 4.0 6.0 x 106 SGPT 31 u/L <41
HGB 14,9 g/dL 12 16 Ureum 21 10-50
HCT 42,8 % 37 48 Creatinine 0,66 0,5-1,2
PLT 278 x 103/uL 150 400 x 103 Natrium 140 136 - 145
Kalium 3,7 3,5 - 5,1
Chloride 109 97 - 111
 LABORATORY FINDINGS

Test Result Normal value

CK 382,10 U/l <190 U/l

CK-MB 72 U/l <25 U/l

Troponin I 0,45 ng/ml <0,01 ng/ml

PT 9,7 detik 10-14 detik

aPTT 21 detik 22-30 detik

INR 0,91 detik --

Kolesterol Total 252 mg/dl <200 mg/dl

Kolesterol HDL 59 mg/dl L(>55); P(>65)

Kolesterol LDL 152 mg/dl <130 mg/dl

Trigliserida 191 mg/dl <200 mg/dl

DIAGNOSIS

ST Elevation Myocardial Infarction (STEMI)

Anteroseptal wall onset <12 hours, KILLIP I
 Management & Planning
treatment & medicine
Bed rest
Oxygen 3 LPM via Nasal canule
NaCl 0,9% 500cc/24h/intravena
Aspilet 80mg/24h/oral
Clopidogrel 75mg/24h/oral
Cedocard 2mg/h/syringe pump
Atorvastatin 40mg/24h/oral
Captopril 12,5mg/8h/oral
Lansoprazole
30mg/24h/intravena
DISCUSSION
INTRODUCTION

Acute coronary syndromes

(ACS) is a term for situations
where the blood supplied to the
heart muscle is suddenly blocked.
described as a group of
conditions resulting from acute
myocardial ischemia
(insufficient blood flow to heart
muscle)
ranging from unstable angina
(increasing, unpredictable
chest pain) to myocardial
infarction (heart attack).
 ACS Classification
19

Acute Coronary Syndrome

A. Unstable angina pectoris
B. NSTEMI
C. STEMI
PATHOPHYSIOLOGY

Occurs when coronary

blood flow decreases
abruptly after a
thrombotic occlusion of
a coronary artery
previously affected
by atherosclerosis.
In most cases,
infarction occurs when
an atherosclerotic
plaque fissures,
ruptures, or ulcerates.
PATHOPHYSIOLOGY

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
RISK FACTORS

Modifiable Non-
Modifiable
 WHO DIAGNOSTIC CRITERIA
Prolonged chest pain
Usually retrosternal location
Ischemic symptoms Dyspnea
Diaphoresis

Inverted T wave
Diagnostic ECG ST segment depression or elevation
changes Pathological Q wave

Troponin-T or I
Serum cardiac CK-MB
marker elevations CK
Myoglobin
CLINICAL PATHWAY
ISCHEMIC SYMPTOMS
 ECG CHANGES

Hyperacute Phase Complete Evolution Old Infarct

Non specific ST- Specific ST-Elevation Q-Pathologic
Elevation T inverted ST segment isoelectric
T taller and wider Q-Pathologic T normal or inverted
CARDIAC BIOMARKERS
GOAL OF TREATMENT

Relieve pain Hemodynamic

stabilization

Myocardial Prevent the

reperfusion complication
MANAGEMENT

Aspirin 160-320 mg 80 mg
Clopidogrel 300 mg --> 75 mg
MONA
M : Morfin
Nitrogliserin/ISDN
O : Oksigen
N : Nitrat
A : Antiplatelet Morfin 1-5 mg
COMPLICATION
PROGNOSIS
KILLIP CLASSIFICATION
CLASS DESCRIPTION MORTALITY RATE (%)

I No clinical signs of heart failure 6

Rales or crackles in the lungs, an S3,

II 17
and elevated jugular venous pressure

III Acute pulmonary edema 30 - 40

Cardiogenic shock or hypotension

IV (systolic BP < 90 mmHg), and evidence 60 80
of peripheral vasoconstriction
Thank
You