Indra Christianto

Adaptasi L.N.

ST Elevation Myocardial
Infarction :
onset 13 Hours, KILLIP I
PATIENT’S IDENTITY
Name : Mr. A.G
Age : 31 y.o
Gender : Male
Medical Record No : 819274
Address : Bantaeng
Date of Admission : Okt 16th 2017
Room : CVCU RSWS
ANAMNESIS
Chief complaint : Chest Pain
Present history :
Chest pain was felt about 13 hours before hospital admission. It was
felt suddenly when the patient was resting. Patient complained about
a burning sensation in the middle of the chest. The pain did not
spread to the arms, shoulder, nor jaw area, also did not penetrate to
the back area. The duration of the pain was >30 minutes. And was
also not relieved by rest or position change. The patient then was
admitted to RSUD in Bantaeng, and was given half tablet of methyl
prednisolone. The pain diminished but was not completely vanished.
After the abnormal ECG, patient received treatment (wasn’t sure what
was the drugs) and then referenced to our hospital. There was no
heart palpitation, no dyspnea, no cough, no nausea or vomiting.
Defecate and urination was normal
PAST HISTORY
There was no history of hypertension.
History of diabetes mellitus was also
denied, there was no history of the same
complain before. There was no other
disease.
FAMILY HISTORY
--------------------------------
There was no family member with the same
complaints
 Could be modified:
✘Hypertenstion(-)
✘Diabetes mellitus (-)
✘Dyslipidemia (-)
✘Obesity (-)
✘Smoking(+) 1 pack a day
✘History of heart disease (-)
Cant be Modified :
• Sex : male
• Age : <50 years
• Family history of heart
disease (-)
 PHYSICAL
EXAMINATION
General State
Interpretation : Moderate Illness
Level of Consciousness : Compos mentis
Nutrition : Sufficient

Vital sign

BP : 120/70 mmHG R: 22x/min HR: 80x/min T:36.5

˚C
Head and Neck
o Anemia : Negative
o Jaundice : Negative
o Cyanosis : Negative
o JVP R + 2 cmH20

Thorax
o Inspection : The right and left are symmetrical, No injury,
No Masses
o Palpation : No tenderness, No crepitus
o Percussion : Sonance
o Auscultation : Vesicular, No Rhonchi and No Wheezing
Heart
o Inspection : Ictus cordis was not appeared
o Palpation : Thrill was not palpable, No Tenderness
o Percussion : Normal Heart Border
o Auscultation : S1 S2 regular, no murmur

Abdomen
Inspection : Due to the breathing movement, no enlargement
Palpation : No tenderness, no enlargement of liver and spleen
Percussion : Tympani
Auscultation : Peristaltic is normal
Extremity
o Inspection : No edema
o Palpation : Warm extrimities
 ELECTROCARDIOGRAM
Interpretation:

• Sinus rhythm
• HR 75x/min
• Normoaxis
• ST elevation
Myocardial
infaction (STEMI)
anteroseptal wall
 Test Result Normal Value

L WBC 20.16 4.00 – 10.0

A
RBC 5.68 4.000 – 6.0

HGB 16.7 12.0 – 16.0

B HCT 47.3 37.0 – 48.0

PLT 274 150 – 400

R Ureum 23 10-50

E Kreatinin 0.77 <1,3

S SGOT 206 <41

U SGPT 52 <38

Na 137 136-145
L K 4.7 3,5-5,1
T Cl 100 97-111

GDS 214 140

LAB RESULT
Test Result Normal Value

CK 3153.75 < 190

CK-MB 308 < 25
Troponin I 7.71 <0.01
ECHOCARDIOGRAM
Interpretation :
• Systolic function of Left Ventricle is decreased.
Ejection fraction 46%
• Diastolic dysfunction grade 2
• Segmental hypokinetic
 DIAGNOSIS
ST Elevation Myocardial Infarction
(STEMI) :
Onset 13 hours, KILLIP I
therapy
✘Oxygen 4 Litre/min binasal
✘IVFD NaCl 0,9 500 cc/ 24 hours/ IV
✘Clopidogrel 75mg/24 hours/ oral
✘Aspilet 80mg /24 hours/ oral
✘Farsorbid 1mg/hours/syringepump
✘Atorvastatin 40mg/24hours/oral
✘Ramipril 2.5mg/24hours/oral
✘Bisoprolol 2.5mg/24hours/oral
✘Arixtra 2.5 mg/24 hours / subcutaneous (already received in
DISCUSSION
What is Myocardial
Infarction?
✘ Commonly known as a heart attack, is
the irreversible necrosis of heart
muscle secondary to prolonged
ischemia.
✘ Results from an imbalance in oxygen
supply and demand, caused by plaque
rupture with thrombus formation in a
coronary vessel, resulting in an acute
reduction of blood supply to a portion
Risk Factor

1. Old People : Individuals aged older than

45 years have an eight times greater
risk for AMI.
2. Male Sex
3. Hypertension
4. Dyslipidemia
5. Diabetes
6. Smoking
7. Obesity and physical inactivity
8. Acute and prolong intake of alcohol
9. Family history
 Coronary Arterial Occlusion.
✘Rupture of high-risk atheromatous plaque in the
coronary arteries is a primary causative factor in the
development of AMI.
✘When exposed to subendothelial collagen and necrotic
plaque contents, platelets adhere, become activated,
release their granule contents, and aggregate to form
microthrombi.
✘Vasospasm is stimulated by mediators released from
platelets
✘Tissue factor activates the coagulation pathway,
adding to the bulk of the thrombus.
Myocardial Response.
✘Coronary arterial obstruction
diminishes blood flow to a region of
myocardium causing ischemia, rapid
myocardial dysfunction, and
eventually—with prolonged vascular
compromise — myocyte death
✘The anatomic region supplied by
that artery is referred to as the
area at risk.
✘The earliest detectable feature of myocyte
necrosis is the disruption of the integrity of the
sarcolemmal membrane, allowing intracellular
macromolecules to leak out of necrotic cells into
the cardiac interstitium and ultimately into the
microvasculature and lymphatics.
✘Intracellular myocardial proteins into the
circulation forms the basis for blood tests that
 CLASSIFICATION
o Anatomic :
1. Transmural infarction- Transmural infarcts
extend through the whole thickness of the heart
muscle and are usually a result of complete
occlusion of the area's blood supply
2. Subendocardial (nontransmural) infarction -
involves a small area in the subendocardial
wall of the left ventricle, ventricular septum,
o Diagnostic
1. ST Elevations Myocardial
Infarction (STEMI)
2. Non-ST Elevations Myocardial
Infarction (NSTEMI)
 Signs and Symptoms
1. Chest Pain
• Most common symptom
• Described as a sensation of tightness, pressure, or
squeezing.
• Not relieved by rest, position change or nitrate
administration.
• Pain radiates most often to the left arm, but may also
radiate to the lower jaw, neck, right arm, back, and
upper abdomen, where it may mimic heartburn.
• Levine's sign, in which a person localizes the chest
pain by clenching their fists over their sternum
SILENT AMI - 20-30% subjects don’t have chest pain, common in patients
with diabetes mellitus, hypertension, & in elderly patients.
2. Nausea and Vomiting
3. Shortness of Breath
• the damage to the heart limits the output of the
left ventricle, causing left ventricular failure
and consequent pulmonary edema.
4. Diaphoresis (an excessive form of
sweating),
5. Light-headedness
6. Palpitations
7. Loss of consciousness
• Due to inadequate blood flow to the brain and
Diagnosis

According to the WHO criteria as

revised in 2000, a cardiac troponin
rise accompanied by either typical
symptoms, pathological Q waves, ST
elevation or depression or coronary
intervention are diagnostic of MI.
Serum Cardiac
Biomarkers

The combination of
CK-MB and troponin
testing have higher
sensitivity and is
used for the
purpose of "ruling
out" myocardial
infarction.
ECG Changes
• ST segment elevation, followed by T wave
inversion and Q waves, are associated
with transmural infarction.
• ST segment depression and T wave
inversion are associated with
subendocardial infarction.
Management
o ONACoM
1. Oxygen
2. Nitroglycerin
3. Aspirin
4. Clopidogrel
5. Morphine (if the pain is not relieved by
nitrogycerin)
o Other early hospital therapy

• Anticoagulant
 Low Molecular Weight Heparin (LMWH)
• Fibrinolytics
• ACE-Inhibitor
• Beta-Blockers (cardiosensitive)
• Statins
Revascularisation Procedure
✘Percutneous Coronary Intervention /
Angioplasty (PCI).
✘Coronary Artery By –Pass (CABG).
✘ Transmyocardial Laser
Revascularization
 PREVENTION
1. Lifestyle Modification
Stop smoking, reduce alcohol intake, excercise
2. Diet
Diets rich in soluble fiber, vegetables, fruits, and
whole grains, and low in saturated fat/trans fat and
cholesterol should be encouraged.
3. Management and control of comorbid diseases
Manage hypertension, and DM
4. Patient education
Patients, their family members, and the community
should be educated properly, especially on how to
detect and respond to an episode of AMI
complications
✘Arrhythmia
✘Hypotension
✘CHF
✘Cardiogenic Shock
Prognosis
KILLIP Classification
Class Definition Patient Proportion Mortality(%)
I Absent cracles and S3 40-50% 6
Cracles in the lower half of the lung
II 30-40% 17
fields ans possible s3
Cracles more than halfway up the
III lung fields and frequent pulmonary 10-15% 30-40
edema
IV Cardiogenic shock 5-10% 60-80
THANKS!
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