Case Report

March 2015

STEMI WHOLE ANTERIOR

ONSET 36 HOURS KILLIP III
By:
Jessica Febrina
Supervisor :
Prof. dr. Peter Kabo, PhD, Sp.FK,
Sp.JP(K),FIHA,FAsCC
Medical Faculty of Hasanuddin University,
Makassar 2015

Patients Identity
Name

: Mr. R

Gender

: Male

Age

: 48 years old

Registration no.

: 703973

Date of admission
Room

: CVCU

: 7 March 2015

History Taking
Chief Complaint:
Chest pain

History of Present Illness:

Left chest pain felt since one day prior to
admission.
Described as compressed pain and radiating to left
arm, intermittently, duration of pain : > 20 minutes
associated with shortness of breath and cold
sweating
dyspnea, nausea and vomiting were present

History of Past Illness

Past Illness History :
History of smoking, 2 packs per day since young
History of chest pain on left chest about 1 year ago
No history of hypertension
No history of Diabetes Mellitus
No history alcohol consumption
No family history of heart disease

Risk Factors
Modified Risk Factor:
-Smoking
-Lack of activity
Non-modified Risk Factor:
-Gender: Male
-Age : 48 years old

PHYSICAL EXAMINATION
General Status
Moderate illness / Normal / Conscious
Weight

: 60 kg

Height : 165 cm
BMI

: 22,00 kg/m2

Vital Status
Blood pressure
Heart rate

: 88 bpm

Respiratory rate
Temperature

:100/70 mmHg
: 20 rpm
: 36,7 oC

Cont
Head

: Anemic (-), icterus (-), cyanosis (-)

Neck

: Lymphadenopathy (-), JVP R+3 cmH2O

Thorax :
Inspection
: Symmetrical left=right
Palpation
: Mass (-), tenderness (-),
normal vocal fremitus
Percussion
: Sonor
Auscultation
: Bronchovesicular, basal
ronchi +/+, wheezing -/-

Cont
Heart :
Inspection : ictus cordis not visible
Palpation : ictus cordis not palpable, thrill (-)
Percussion : Dull
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea axillaris anterior sinistra

Auscultation
murmur (-)

: heart sound I/II pure, regular,

Cont
Abdomen :
Inspection : flat and follows breath movement
Auscultation
: Peristaltic sound (+), normal
Palpation : Liver and spleen unpalpable
Percussion : Tympani (+), ascites (-)
Extremities :
Edema (-)

LABORATORY FINDINGS
TEST

RESULT

NORMAL VALUE

Glucose

103 mg/dL

<140

SGOT

500 u/L

<38

SGPT

103 u/L

<41

Ureum

70

10-50

TEST

RESULT

NORMAL VALUE

Creatinine

1,1

0,5-1,2

WBC

22,6x 103/uL

4.0 10.0 x 103

Troponin T

>2,0

<0,05

RBC

5,09 x 106/uL

4.0 6.0 x 106

CK

4699,0

<190

HGB

15,0 g/dL

12 18

CKMB

233,3

<25

HCT

45,0%

37 48

Natrium

137

136 - 145

PLT

388 x 103/uL

150 400 x 103

Kalium

4,8

3,5 - 5,1

PT

9,8

10 - 14

Chloride

101

97 - 111

APTT

30,7

22,0 - 30,0

Uric Acid

4,8

3,4-7,0

ELECTROCARDIOGRAPHY

Sinus rhythm
HR
: 113 bpm
Axis
: normoaxis
PR-Interval : 0.12 sec
P-Wave
: 0.8 sec
QRS Duration
: 0.8
sec
ST-segment : ST
elevation on V1-V5
T-wave
: Normal

Conclusion
Sinus tachycardi,
normoaxis, HR 113 bpm, ST
elevation on V1-V5, (whole
anterior wall myocardial
infarction)

CHEST XRAY

Result :
Cardiomegaly (CTI
index : 0.61)
Pulmonary edema
Pleural effusion
dextra
:
Card

DIAGNOSIS

ST Elevation Myocardial
Infarction (STEMI) Whole
Anterior, onset 36 hours, Killip
III

MANAGEMENT

Bed rest
O2 2-4 lpm via nasal cannula
IVFD NaCl 0,9% 500 cc/24 hours/IV
Aspirin 80 mg/24 hours/oral
Clopidogrel 75 mg/24 hours/oral
Captopril 6,25mg/8 hours/oral
Fondaparinux 2,5mg/24 hours/subcutaneous
Isosorbide Dinitrate 1mg/hour/syringe pump
Furosemide 40 mg/12 hours/ IV
Ceftriaxone 2gr/24 hours/IV
Laxadine syr 10cc/24 hours/oral
Alprazolam 0,5 mg/ 24 hours/oral

PLANNING

Echocardiography
Coronary angiography

DISCUSSION

DEFINITION
Myocardial infarction (MI) is a
rapid development of myocardial
necrosis caused by a critical
imbalance between the oxygen
supply and demand of the
myocardium. This usually results
from
plaque
rupture
with
thrombus formation in a coronary
vessels, resulting in an acute
reduction of blood supply to a
portion of the myocardium.
European Heart Journal 2012: ESC Guidelines

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.

European Heart Journal 2012: ESC Guidelines

DIAGNOSIS

ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment
elevation. European Heart Journal (2011)

Unstable Angina

NSTEMI

STEMI

Non occlusive
thrombus

Occluding
thrombus
sufficient to cause
tissue damage &
mild
myocardial
necrosis

Complete thrombus
occlusion

Non specific
ECG

ST depression +/T wave inversion

on
ECG

ST elevations on
ECG or new LBBB

Normal cardiac
enzymes

Elevated cardiac
enzymes

Elevated cardiac
enzymes

RISK FACTORS
Nonmodifiable

Gender and Age

Men, increased
risk > age 45
Women, increased
risk > age 55
Family History
CAD diagnosed
before age 55 in
father or male
siblings
CAD disease
diagnosed before
age 65 in mother or
female siblings

Modifiable

Smoking
Hypertension
Diabetes
Mellitus
Dyslipidemia
Obesity
Lack of physical
activity

Diagnosis Of ACS
At least 2 of the followings:

Ischemic
symptoms

Diagnostic
ECG changes

Serum cardiac
marker
elevations
Oxford Handbook of Clinical Medicine 6 th Edition

Diagnosis Of ACS
Ischemic symptoms

Prolonged pain
(usually >20
minutes)
constricting,
crushing, squeezing
Usually retrosternal
location, radiating
to left chest, left
arm; can be
epigastric
Dyspnea
Diaphoresis

Oxford Handbook of Clinical Medicine 6th Edition

Palpitations

Diagnosis Of ACS
Diagnostic ECG changes

Patophysiology of Heart Disease - A Collaborative Project of Medical Students and Faculty Leonard S Lilly, 5th edition

Diagnosis Of ACS
Serum cardiac marker
elevations
Troponin T
CK-MB
CK
Myoglobin

Patophysiology of Heart Disease - A Collaborative Project of Medical Students and Faculty Leonard S Lilly, 5th edition

INFARCT LOCATION

Fauci, Braunwald, dkk. 17thEdition Harrisons Principles of Internal Medicine. New South Wales: McGraw

GOAL OF TREATMENT
Relieve pain
Myocardial perfusion
Hemodynamic stabilization
Prevent the complication

a report of the American College of Cardiology American Heart Association Task Force on Practice Guidelines. 2008;51:210

MANAGEMENT

Bed rest
Oxygen (2-4 lpm)
Anti platelet therapy :
-Aspirin 162-325mg chewed immediately and 81162 mg continued indefinitely.
-Clopidogrel 300-600mg loading dose and 75mg
daily continued for at least 14 days and up to 12
months.
Nitroglycerin :
0.4 mg SL tablets every 3-5 min up to 3 times; if
effect is not sustained, can continue with an IV
drip of 50mg in 250mL Dextrose 5%.

MANAGEMENT

Morphine 2-5mg iv (can be administered again in

5-30 minutes later)
Fibrinolytic therapy:
-Streptokinase 1.5million units iv
-Tenecteplase 0.5mg/kg body weight iv
Anticoagulation therapy:
-Low Molecular Weight Heparin (Fondaparinux)
2.5mg/24hrs/sc for up to 8 days post-MI.
-Unfractionated heparin : Bolus 60units/kg body
weight (maximum 4000U), infuse 12units/kg body
weight/hour (maximum 1000U/hour)
Anti Hypertensive Drugs
Lipid Lowering Agents

European Heart Journal 2012: ESC Guidelines

COMPLICATIONS
Arhythmia
Congestive Heart Failure
Cardiogenic shock
Thromboembolism
VSD

TIMI RISK SCORE FOR STEMI

Risk Factor
Age > 65 years old
Age > 75 years old

Score
2
3

Risk of
Total
Death in 30
Score
days
0
0.8%
1
1.6%
2
2.2%
3
4.4%
4
7.3%
5
12.4%
6
16.1%
7
23.4%
8
26.8%
9-14
35.9%

History of
angina/hipertension/D 1
M
Systolic BP <100
3
Heart rate > 100
2
Killip II-IV
2
Weight > 67kg
1
Anterior MI or LBBB
1
Delay
treatment
Acute coronary
syndrome, 3rd ed.Revised and expanded

KILLIP CLASSIFICATION

Class
Description
I
no clinical signs of heart failure
II

III
IV

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

Mortality Rate (%)

6

17

30 - 40
60 80

Acute coronary syndrome, 3rd ed.Revised and expanded

THANK YOU