JULI 2018

CASE REPORT:
ST Elevation Myocardial Infarction (STEMI) Whole
Anterior Wall onset <6 hours KILLIP I

Presented by:

Nur Nazmi Selan C111 08 366

Supervisor:
dr. Zaenab Djafar, Sp.PD, FINASIM, Sp.JP,FIHA
 Patient’s Identity

 Name : Mr.H
 Gender : Male
 Age : 46 years old
 Registration no. : 845216
 Date of Admission : 03/07/2018
 History Taking

Chief Complaint:
Chest pain
Guided Anamnesis:
Left chest pain is experienced within 5 hours before admitted to the
hospital. The pain was felt at the left side of the chest, The duration of
the chest pain occurs about ± 10 minutes. radiated to the back
associated with cold sweat. There is no shortness of breath. There was
no nausea and vomitting. Urination and defecation normal.
 Past Illness History

• No history of hypertension
• No history of Diabetes Mellitus
• No history of cardiovascular disease before
• No History of alcohol consumption
• History of smoking (+) within 10 years
• No history of previous chest pain and heart disease
• No family history with heart disease
 Risk Factors

Non-Modified Risk Factor :

 Gender Male
 Age > 45 years old

Modified Risk Factor :

 Smoking
PHYSICAL EXAMINATION
 General Status
 Moderate illness / Overweight/ Composmentis
 Weight : 58 kg
 Height : 165 cm
 BMI : 20.71 kg/m2
 Vital Status
 Blood pressure :130/80 mmHg
 Heart rate : 80 bpm
 Respiratory rate : 20 rpm
 Temperature : 36,5 oC
PHYSICAL EXAMINATION
Head Examination
• Eyes : anemic (-/-), icterus (-/-), cyanosis (-/-)
• Neck : tumor mass (-), tenderness (-),
JVP R+1 cmH2O, trachea deviation (-)

Chest Examination
• Inspection : symmetric right=left
• Palpation : mass (-), tenderness (-),vocal fremitus right=left
• Percussion : sonor right=left
lung-hepar border=right ics iv
right back lung border = right cv th viii
left back lung border = left cv th ix
• Auscultation : breath sound : vesicular
additional sound : ronchi (-/-),wheezing (-/-)
PHYSICAL EXAMINATION
Cardiac Examination
• Inspection : ictus cordis not visible
• Palpation : ictus cordis is not palpable, thrill (-)
• Percussion : normal heart size
• Auscultation : Regular of I/II heart sound,
murmur (-)
Abdominal Examination
 Inspection : flat and following breath movement
 Auscultation : peristaltic sound normal
 Palpation : liver and spleen not palpable
 Percussion : tympani, ascites (-)
Extremities
- Oedema : pretibial (-/-), dorsum pedis (-/-)
ELECTROCARDIOGRAM
Pre trombolitik
09/10/2017

Rhythm : sinus rhytm

Heart Rate : 77 bpm Duration of QRS : 0.08 sec
Regularity : reguler ST segment : elevation in V1-V4
P wave : 0.10 sec
PR interval : 0.12 sec Conclusion:
Axis : LAD Stemi Anterior
ELECTROCARDIOGRAM
Post trombolitik
05/07/2018

Rhythm : sinus rhytm Duration of QRS : 0.08 sec

Heart Rate : 62 bpm ST segment : elevation in V1-V4,
Regularity : reguler
P wave : 0.10 sec Conclusion:
PR interval : 0.12 sec Stemi Anterior
Axis : LAD
 LABORATORY FINDINGS
TEST RESULT Normal value

RBC 5,11 x103/l 4,00-6,00x103/l

WBC 13,5 x103 /l 4,0-10,0 x 103 /l

HGB 15,9 gr/dl 12,0-16,0 g/dl

HCT 44% 37,0-48,0 %

PLT 271x 103 /l 150-400 x 103 /l

GDS 154 mg/dl 140 mg/dl

Ureum - mg/dl 10-50 mg/dl

Creatinin 0,71 mg/dl M(<1,3);F(<1,1) mg/dl

SGOT - U/l <38 U/l

 LABORATORY FINDINGS
Test Result Normal value

SGPT - U/l <41 U/l

Natrium - mmol/l 136-145 mmol/l

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

Klorida - mmol/l 97-111 mmol/l

CK - U/l L(<190)P(<167) U/l

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

Troponin I 0,35 ng/ml <0,01 ng/ml

PT - detik 10-14 detik

APTT - detik 22-30 detik

INR - detik --
WORKING DIAGNOSIS
 ST Elevation Myocardial Infarction (STEMI) Whole Anterior
Wall onset < 6 hours KILLIP I
THERAPY
 Oksigen 4 lpm via nasal canul
 IVFD NaCl 0,9 % 500 cc/24 hour
 Aspilet 80mg/24 hours/oral
 Clopidogrel 75 mg/24 hours/oral
 Actylise : 15 mg bolus intravena
35 mg drips 30 second
 Cedocard 1mg/hours/syringpump
 Atorvastatin 40 mg/24 hours/oral
 Bisoprolol 2,5 mg/24 hours/oral
 Captopril 12,5 mg/8 hours/oral
 Alprazolam 0,5mg/24 hours/oral
 Arixtra 2,5mg/24 hours/subcutan 5 hari
 Laxadine syrup 10cc/24 hours/oral
 DISCUSSION
ST elevation Myocardial infarction
INTRODUCTION

Acute coronary syndromes (ACS) is a term for situations where

the blood supplied to the heart muscle is suddenly blocked
INTRODUCTION
 Myocardial infarction (MI)  rapid development of
myocardial necrosis caused by a critical imbalance
between the oxygen supply and demand of the Definition
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
Regions of the Myocardium

Lateral
I, AVL,V5-V6

Inferior
II, III, aVF Anterior / Septal
V1-V4
• 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
 Unstable NSTEMI STEMI
Angina
Occluding thrombus Complete thrombus
Non occlusive sufficient to cause occlusion
thrombus tissue damage & mild
myocardial necrosis ST elevations on
Non specific ECG or new LBBB
ECG ST depression +/-
T wave inversion on Elevated cardiac
Normal cardiac ECG enzymes
enzymes
Elevated cardiac More severe
enzymes symptoms
 WHO DIAGNOSTIC CRITERIA
• Prolonged chest pain
Ischemic Usually retrosternal location
symptoms • Dyspnea
• Diaphoresis

Diagnostic ECG • Inverted T wave

• ST segment depression or elevation
changes • Pathological Q wave

Serum cardiac • Troponin-T atau I

• CK-MB
marker • CK
elevations • Myoglobin
 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
GOAL OF TREATMENT

Hemodynamic
Relieve pain
stabilization

Myocardial Prevent the

reperfusion complication
Thrombolytic
ALTEPLASE

Alteplase 15 mg bolus iv.

50mg iv in 30minutes

35mg iv in 60minutes
Initial Treatment
 Bed rest
 Oxygen (2-4 lpm)
 Anti platelet therapy :
 Aspirin 160-320mg chewed immediately and 80-160 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%.
 Morphine 2-5mg iv (can be administered again in 5-30 minutes later)
 Fibrinolytic therapy:
 Streptokinase 1.5 million units in 100 mL dextrose 5% or NaCl 0,9% finished in 30 – 60 minutes
 Actilyse : 15 mg bolus iv
0.75mg/kg weight body in 30 minutes
and 0,5 mg/kg weight body in 60 minutes
 Anticoagulation therapy:
 Low Molecular Weight Heparins (Fluxum) 0.4cc/sc for up to 8 days post-MI.
 Unfractionated heparin

 Anti Hypertension Drugs

 Lipid Lowering Agents
COMPLICATION
PROGNOSIS
KILLIP CLASSIFICATION

CLASS DESCRIPTION MORTALITY RATE (%)

I No clinical signs of heart failure 6

Rales or crackles in the lungs, an S3, and

II 17
elevated jugular venous pressure

III Acute pulmonary edema 30 - 40

Cardiogenic shock or hypotension (systolic

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