AGUSTUS 201

CASE REPORT:
STEMI EXTENSIVE ANTERIOR
ONSET < 12 HOURS + TROMBOLITIK

Presented by:

Muhammad Syahir Bin Tajuddin C111 12 865

Alif Zulfikar Supardi C111 12 895

Supervisor:
Dr. dr. Idar Mappangara, Sp.PD, Sp.JP,
FIHA, FINASIM
PATIENT IDENTITY
Name : Mr. R
Age : 23 years old
Address : Jl. Monumen Emmy Saelan
Lr 6, Makassar
MR : 764573
Date of Admission : 16/7/2016
HISTORY TAKING

Chief complaint : Chest pain

Present Illness History :
Suffered since 10 hours before admission
Described as squezzed and compressed pain on the left
side,intermittently, duration of pain : 20-30 minutes,
associated with diaphoresis.Trombolytic has been given at
RSI Faisal before being refer to RSWS
The intensity is not influeced by activity or rest
Orthopneu (-)
Dyspneu On Effort (-)
Paroxysmal Nocturnal Dyspneu (-)
Nausea (-), Vomit (-)
HISTORY TAKING
Past Illness History :
History of chest pain 1 year ago
History of hypertension was denied
History of Diabetes Mellitus was denied
No family history with heart disease

Lifestyle History:
History of smoking (+), since 7 years ago, 2 packs (32 bar)/day.
History of alcohol consumption (+)
History of excessive junk food consumption
RISK FACTOR
Modified Risk Factor
Smoking
Obesity
Dyslipidemia
Lack Of Physical Activity

Non-modified risk factor:

Gender : Male
PHYSICAL EXAMINATION
General Status
Moderate illness / Obesity/ GCS 15 (Compos mentis)
Weight : 85 kg
Height : 170 cm
BMI : 29,4 kg/m2
Vital Status
Blood pressure :100/80 mmHg
Heart rate : 88 bpm
Respiratory rate : 22 rpm
Temperature : 36,8 oC
PHYSICAL EXAMINATION

Head: anemic (-) icteric (-)

Neck : JVP R+2 cmH2O,
Lung :
Inspection : symmetry left=right
Palpation : mass (-), no tenderness, normal vocal
fremitus
Percussion : sonor
Auscultation : vesicular, ronchi -/-, wheezing -/-
 PHYSICAL EXAMINATION
Cor :
Inspection : ictus cordis not visible
Palpation : ictus cordis palpable, thrill (-)
Percussion :
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea midclavicularis sinistra
Auscultation : heart sound I/II regular, murmur (-)
PHYSICAL EXAMINATION

Abdomen :
Inspection : flat, follows breath movement
Auscultation : peristaltic (+), normal
Palpation : liver and spleen not palpable
Percussion : tympani

Extremities :
Edema (-)
ELECTROCARDIOGRAPHY
Sinus rhythm
Heart rate : 79 bpm
Axis : Normoaxis
P Wave : 0,08 s
PR interval : 0,12 s
QRS Duration : 0,16 s
QRS complex : Poor R
waves progression
ST segment : ST
elevation on lead I, aVL,
V1-V5
T Wave : normal

Conclusion :
Sinus rhytm, HR
79x/mnt, normoaxis,
STEMI ekstensive
anterior
 LABORATORIUM RESULTS

TEST RESULT Normal value

RBC 5,69 x106/l 4,50-6,50x106/l

WBC 15,7 x103 /l 4,0-10,0 x 103 /l

HGB 16,2 g/dl 14,0-18,0 g/dl

HCT 51 % 40,0-54,0 %

PLT 272x 103 /l 150-400 x 103 /l

 LABORATORIUM RESULTS
Test Result Normal value

Random blood glucose (GDS) 184 mg/dl 140 mg/dl

Ureum 22 mg/dl 10-50 mg/dl

Creatinin 0,9 mg/dl M(<1,3);F(<1,1) mg/dl

SGOT 503 U/l <38 U/l

SGPT 125 U/l <41 U/l

Natrium 142 mmol/l 136-145 mmol/l

Kalium 4,3 mmol/l 3,5-5,1 mmol/l

Klorida 106 mmol/l 97-111 mmol/l

 LABORATORIUM RESULTS
Test Result Normal value
CK-MB 296 U/l <25 U/l

Troponin I >10 ng/ml <0,01 ng/ml

PT 9,7 detik 10-14 detik

aPTT 24,5 detik 22-30 detik

INR 0,93 detik --

Total Cholesterol 194 mg/dl <200 mg/dl

HDL 27 mg/dl L(>55); P(>65)

LDL 142 mg/dl <130 mg/dl

Triglyceride 126 <200 mg/dl

 CHEST X-RAY

Conclusion:
Bronchovascular normal
No specific active process at both lung
Cardiomegaly
 ECHOCARDIOGRAPHY
Decrease left ventricular systolic
function
Normal right ventricular systolic function
Segmented hypokinetic
Ventricular Diastolic dysfunction grade II
DIAGNOSIS

ST Elevation Extensive Anterior Myocardial

Infarction (STEMI) onset <12 hours, KILLIP I
TREATMENT
Oxygen 2-4 litre/minute via nasal canule
IVFD NaCl 0,9% 500 cc/24 hours/IV
Aspilet 80 mg/ 24 hours/oral
Clopidogrel 75 mg/ 24 hours/oral
Lovenox 06 cc/12 hours/oral
Captopril 12.5 mg/8 hours/ oral
Isosorbid Dinitrat 1 mg/ hours/ syringepump
Atorvastatin 20 mg/24 hours/oral
Laxadyn 15 cc/24 hours/oral
Alprazolam 0.5 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.
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)
 20

ACS Classification

Acute Coronary Syndrome

A. Unstable angina pectoris
B. NSTEMI
C. STEMI
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
Regions of the Myocardium

Lateral
I, AVL,V5-V6

Inferior
II, III, aVF Anterior / Septal
V1-V4
RISK FACTORS

Non-
Modifiable
Modifiable
Smoking Gender & Age
Hypertension Men > 45 years old
Women > 55 years old
Diabetes mellitus
Hypercholesterolemia Family history
Obesity Heart disease in biological
brother or father < 55 years
old
Psychosocial stress Heart disease in biological
sister or mother < 65 years old
Lack of physical activity
CLINICAL PATHWAY
WHO DIAGNOSTIC CRITERIA
Prolonged chest pain
Ischemic Usually retrosternal location
Dyspnea
symptoms Diaphoresis

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

Serum cardiac Troponin-T atau I

CK-MB
marker CK
elevations Myoglobin
ECG CHANGES

Hyper acute Phase Complete Old Infarct

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

Hemodynamic
Relieve pain
stabilization

Myocardial Prevent the

reperfusion complication
 Reperfusion Therapy for Patients with STEMI

*Patients with cardiogenic shock or severe heart failure initially seen at a nonPCI-capable hospital should be transferred for cardiac
catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). Angiography and
revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
- Reperfusion Therapy -
Thrombolitik
ALTEPLASE

Alteplase 15 mg bolus iv.

0.75 mg/kg (50mg) iv in 30minutes

0.5 mg/kg (35mg) iv in 60minutes

 TREATMENT
Clinical Study shows:
Bisoprolol -Limit area of MI
-re-infarction risk decrease
-prolong life span
Relieve symptom
NTG
Vasodilatation

-Plaque stabilization
-LDL decrease Atorvastatin
target: <70mg/dl -Anti-remodelling
-decrease mortality

Captopril
TREATMENT
O2 2-4 L/min 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
Captopril 12,5 mg/12jam/oral
Bisoprolol 1.25mg/24jam/oral
Nitroglycerin 1mg/jam/SP
Atorvastatin 40mg/24 hours/oral
Arixtra 2,5 mg/24 hours/subcutaneous
Laxadine syr 0-0-2 tsp
Alprazolam 0,5 mg 0-0-1
ACC/AHA 2007 recommendation:
Loading: Aspirin 300mg
Decrease mortality
Clopidogrel 300mg Decrease re-infarction rate

CURE study reported:

Maintanance:
Aspirin 80mg+Clopidogrel 75mg (for1year)

decrease 20% mortality risk,

infark myocardial non fatal,
stroke
COMPLICATION
PROGNOSIS
KILLIP CLASSIFICATION
MORTALITY RATE
CLASS DESCRIPTION
(%)

I No clinical signs of heart failure 6

Rales or crackles in the lungs, an

II S3, and elevated jugular venous 17
pressure

III Acute pulmonary edema 30 - 40

Cardiogenic shock or hypotension

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