Case Presentation

Acute Myocardial Infarction

with ST Segment Elevation

BY : ST. HAMIDA SALEH

SUPERVISOR :
DR. IDAR MAPPANGARA,Sp.PD,SP.JP(K),FIHA

Patient ID
Name

: Mr. P
Age
: 46 years old
Address
: Bulukumba
Medical Record : 386399
Date of Admittance : 30th April 2009

History Taking
Chief Complaint : Chest Pain
History Taking :

Patient admitted in Wahidin hospital at 04.00pm with

chief complaint is pain of his left and right chest since
early morning at 05.00am. The pain appeared suddenly
after he prayed. This pain is the first time he felt and was
described as a pressure sensation in the mid of the thorax,
and also feel like sticked by needle and radiated to his
back, arm and didnt reduced by rest. He also felt
palpitation. This patient was referenced by Bulukumba
hospital and has given Nitrat SL but it has not responsed.
He deny that he has breathless, abdominal pain, cough,
Fever, nausea, vomiting. Micturity and defecation were
normal.

Past Illness History

Diabetes mellitus (-)

Hypertension (-)
Heart disease (-)
Gastritis (-)
Family history of heart disease (-)

Risk Factor
Gender : Male
Dislipidemia (+)
Hypertension (-)
Smoking history (+)
Alcohol (-)
Obesity (+)
Diabetes Mellitus (-)

Physical Examination
General Appearance :
Moderate-illnes/obesity(29,4)/conscious
Vital Sign :
Pulse : 72 bpm
Blood Pressure : 140/90 mmHg
Inspiratory rate : 24 tpm
Body temperature : 36.7 C
Head Examination :
Eyes : no anemia, no jaundice, no cyanosis
Neck : JVP R-2 cmH20
Thoracic Examination :
Inspection : Symmetric sinistra et dextra
Palpation : no mass, no tenderness
Percussion : Sonor
Auscultation : Breath Sound was vesicular, no extra sound

Physical Examination
Cardiac Examination :

Inspection : Ictus Cordis wasnt visible

Palpation : Ictus Cordis wasnt palpable
Percussion : dullness
Auscultation : regular of I/II Heart Sound, no murmur

Abdominal Examination :

Inspection : Normal
Palpation : no mass palpable, no tenderness
Percussion : tympani
Auscultation : peristaltic sound (+), normal

Extremities :

No limbs oedema

Laboratory Examination
Complete blood
WBC
: 12.6 x 103 /mm3
()
HGB
: 14,6 g/dl
HCT
: 44,3 %
RBC
: 5,31 x 106 /mm3
PLT
: 267 x 103 /mm3

Cardiac enzyme
CK
: 3921()
CK MB
: 563 u/L ()

Blood chemistry
Random blood sugar
: 96
mg/dl
SGOT
: 20 u/l
SGPT
: 9 u/l
Total Cholesterol : 229
mg/dl()
HDL
: 24
mg/dl()
LDL
: 133mg/dl
()
Triglyseride
: 159 mg/dl

Electrocardiogram

Electrocardiogram
Sinus Rhythmic
Heart rate 88 bpm
Axis : LAD
ST Segment : Elevation at L1 V1 V3, V4 V6
Recent anteroseptal lateral Infark Miokard

Echocardiogram

Echocardiogram

Hypokinetic AnteroSeptal
EF 46%
E/A >1
LVH

Conclusion:
Disfunction Sistolic

Suggestion examination
Thorax radiography
Coronary angiography

Diagnosis
Infark Miokard with ST Segment Elevation

Management

Bed rest
Cardiac Diet
O2 4 6 Lpm
IVFD NaCl 0,9 % 12 dpm
Streptokinase 1,5 million unit in a hour
Plavix (clopidrogel) 75 mg 1x1
Aspilet (aspirin) 80 mg 1x1
Isoket (Isosorbit IV) 2mg/ hour
Lovenox (Heparin) 0,6cc/24 hour/ SC
Captopril (ACE inhibitor) 12,5 mg 1-0-1
Simvastatin 20 mg 0-0-2
Alprazolam 0,5 mg 1/2-0-1
Laxadine syr 3 x 1 c

Discussion
ACUTE MYOCARDIAL
INFARCTION

Definition
Myocardial infarction (MI) is the 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.

Pathophysiology
STEMI generally 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 and when conditions
favor thrombogenesis
Histologic studies indicate that the coronary plaques prone
to rupture are those with a rich lipid core and a thin fibrous
cap.

Risk Factor for

Myocardial infarction

GENDER

HYPERTENSION

DIET

HYPERLIPIDEMIA

AGE > 45 y.o

SMOKING

FAMILY HISTORY

Clinical features
Presenting complaint :

Chest pain, >30 minutes

Usually tight, crushing, and band like
Location in retrosternal
May radiate to left arm, throat, and jaw
Associated features including palpitation, sweating,
breathlessness, and nausea.

Diagnose
Signs of myocardial ischemia
ECG
ST segmen elevation ?

No

Acute Myocardial Infarction

( Q-wave, non-Q wave )

Lab

Biochemical cardiac markers ?

No

Yes

Yes

NSTEMI
( No ST-Segment
Elevation
Myocardial Infarction )
Unstable Angina

Electrocardiogram
Classic ECG changes of a full-thickness MI are as follows :
ST segment elevation over area of damage
ST depression in leads opposite infarction
Pathological Q waves
Reduced R waves
Inverted T waves

Indicators of myocardial damage

Creatinine Kinase (CK)MB
Cardiac spesific Troponin (cTn)T or (cTn)I
Creatinin Kinase (CK)

Management
Bed rest
Diet
Oxygen
Fibrinolytic
Aspirin and/or anti platelet agent
-blocker
Nitrates
Anti Trombolitic
ACE inhibitors
Lipid lowering agent
Surgical care ( PCI or CABG )

Complication to aware
Early : arrhytmias, cardiogenik shock due to heart

failure
Medium term : rupture of papillary muscle,
rupture of interventricular septum, free wall
rupture
Late : cardiac failure, left ventricular aneurysm,etc

Thank you