CASE REPORT

MIOCARDIAL INFARCT WITH ST

ELEVATION
By : Nurul Wahidah binti Tumin – C11113812

Supervisor : dr. Pendrik Tandean, SpPD-KKV,FINASIM

 PATIENT IDENTITY

 Name : Mrs MB
 Date and place of birth : 26th August 1948 / Jl. AP. Pettarani
 Age : 69 years old
 Sex : Woman
 Medial record’s number : 793645
 Date of admission : 6th April 2017
 Date of discharged : 8th April 2017
 Ward : 3rd floor (Perawatan) , Cardiac center
 HISTORY TAKING

CHIEF COMPLAINT CHEST PAIN

PRESENT ILLNESS HISTORY
→cold sweat (Diaphoresis)
→ chest pain radiating to left hand, →dyspnea
feels depressed and penetrating to the → paroxysmal nocturnal dyspnea
back of body , location of pain is → syncope (-)
unrecognized specifically → no nausea and vomiting
→ since 1 month ago → no fever
→ increasing with activity, reduce while
resting
→ duration 20-30 minutes intermittent
RISK FACTORS
Non-modified:
→ Age : 69 years old, Female
Modified:
→Diabetes Mellitus with Insulin treatment
regularly.
→Heart disease since 1 month ago
→Depressed after her husband die 13 years ago.

PREVIOUS MEDICAL HISTORY

→ Heart disease since 1 month ago
→Diabetes Mellitus type II for a long period (patient do not remember the
exact period)
→ Have history of warded for 12 days 1 month ago with same complaint
→ Do not have history of hypertension, tuberculosis
→ Do not have family history with same disease/complaint
 PHYSICAL EXAMINATION
VITAL SIGNS
• General : Moderate pain
• Nutrition : Good
• GCS : E4M6V5
• Body weight : 55 kg
• Height : 155 cm
• BMI : 22.89 kg/m2
• Blood Pressure : 120/80 mmHg
• Heart rate : 62x /minute
• Respiration : 20x/minute
• Temperature : 36,5ᵒC
Eye:
• No Anemia, No icterus
• Equal pupil
• No eyelid edema

Neck:
• JVP: R+2cmH2O
• No gland enlargement

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

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

EKSTRIMITIES
• Edema : Absent
ELECTROCARDIOGRAPHY

ST-
elevation
and T
inverted at
lead
V1,V2,V3
Rhythm : normal QRS complex : Normal, 0,16s
Heart Rate : 63 bpm Duration of QRS : 0.12sec
Regularity : regularly ST segment : ST elevation in V1-V3
P wave : Normal, upright, 0.08 sec T wave : T inverted in V1-V3
PR interval : 0.20 s
Axis : Normoaxis

Conclusion: Sinus rhythm, HR 63 bpm, normoaxis, anteroseptal

wall infarct, hypertrophy left ventricle
 LABORATORY TEST RESULT
HEMATOLOGY
• WBC : 8,8x10^3ul
• RBC : 3,84X10^6ul
• HGB : 11,6 gr/dl
• HCT : 35%
• LYMPH : 18.8%
• PLT : 267x 10^3 uL
LIVER FUNCTION
• SGOT : 48 U/L
• SGPT : 85 U/L
COAGULATION
BLOOD CHEMISTRY CARDIAC MARKER
FACTOR
• APTT : 21.3 s • Glucose (GDS) : 193 • CK-MB : 25.4 U/L
• PT : 10.1 S mg/dl • Troponin I : 0.16
ng/ml
• CK : 104.95 U/L
KIDNEY FUNCTION ELECTROLYTE
• Ureum : 40 mg/dl • Natrium : 138
• Creatinin : 0.96 mmol/l
mg/dl • Kalium : 4.7 mmol/l
• Cloride : 104
mmol/l
 THORAX X-RAY PHOTO

RESULT
• Diffuse consolidation at perihilar and pericardial both
lung
• Cor : enlarged, aorta calcification
• Sinus and diaphragm normal
• The bones intact

CONCLUSION
• Cardiomegaly with acute lung edema
• Atherosclerosis aortae
 ECHOCARDIOGRAPHY

CONCLUSION
• Systole function at left ventricle decrease, EF 31%
• Dilatation of left ventricle
• Hypertrophy of left ventricle eccentric
• Segmental akinetic and hypokinetic
• Moderate mitral regurgitation
• Mild triscuspidal regurgitation
• Mild pulmonal regurgitation
• Severe dysfunctional of left ventricle
 DIAGNOSIS

Myocardial infarct with ST elevation at

anterosepthal wall onset >24 hours Killip 2
Diabetes Mellitus type II
 THERAPY
Oxygen 3L / minute / nasal cannula

Natrium chloride 0,9% 500cc / 24 hours/ pro infus

Aspilet Chewable 80mg / 24hours / oral

Clopidogrel Tab 75mg / 24 hours / oral

Farsorbid Tab 10mg / 8 hours / oral

Atorvastatin 40mg / 24 hours / oral

Captopril Tab 12,5mg / 8 hours / oral

Bisoprolol 2.5 mg / 24 hours / oral

Lansoprazole 30 mg / 12 hours / oral

Sucralfate Suspension 100 mL / 10cc / 8 hours / oral

NovoRapid Flex Pen 100 IU/ml 3 mL 6-6-6/ 8 hours/ Subcutaneous

Levemir FlexPen 100 IU/ml 0-0-10 / 24 hours / Subcutaneous

DISCUSSIONS
ACUTE CORONARY SYNDROME

MIOCARDIAL INFARCT WITH ST

ELEVATION

ACUTE
MIOCARDIAL INFARCT WITH NON ST
CORONARY
ELEVATION
SYNDROME

UNSTABLE ANGINA PECTORIS

ACUTE CORONARY SYNDROME

Acute coronary syndrome

(ACS) refers to any group of
symptoms attributed to
obstruction of the coronary
arteries.
 DIAGNOSIS
At least 2 of these following criteria (WHO)
Ischemic symptoms
• Prolonged chest pain usually retrosternal location
• Dyspnea
• Diaphoresis

Diagnostic ECG changes

• Inverted T wave
• ST segment depression or elevation
• Pathological Q wave

Serum cardiac marker elevations

• Troponin-T or Troponin I
• CK-MB
• CK
• Myoglobin
ST-ELEVATION MIOCARDIUM INFARCT

A transmural infarction of the myocardium → entire thickness of

the myocardium has undergone necrosis.

Occurs when blood flow of artery coronary suddenly decreased

after occlusive thrombus on atherosclerotic plaque.

Coronary plaques tend to rupture if it has a thin fibrous cap and a

lipid-rich core.

Classical pathological → rich red fibrin thrombus = believed to

be the basis of so STEMI response to thrombolytic therapy.
 PATHOPHYSIOLOGY

Lipid pool Procoagulant

Inactivated platelet
underneath of the Activated platelet environment
will adhesive there
blood vessel happen

Complicated
Thickening of the lesion→fissure and
Fibrocalcific lesion
fibrous wall hematoma or
deposit of thrombus
 RISK FACTORS

Non-modified Modified

• Gender • Hypertension
• men >women • Diabetes Mellitus
• Age • Dyslipidemia
• Men : >45 • Obesity
• Women : >55 • Smoking
• Family history • Diet
• Stress
 ISCHEMIC SYMPTOMS
Prolonged pain (usually >20 mins), constricting,crushing, squeezing

Usually retrosternal location, radiating to left chest, left arm, can be

epigastric

Dyspnea

Diaphoresis

Palpitations

Nausea/vomiting

Light headedness
 CARDIAC CARE COALS

Decrease
Prevent major
amount of Preserve LV
adverse
myocardial function
cardiac events
necrosis

Treat life
threatening
complications
 TREATMENT

Initial labs and tests Emergency Care History &physical

• 12 lead ECG • IV access • Establish diagnosis

• Obtain initial cardiac • Cardiac monitoring • Read ECG
enzymes • Oxygen • Identify
• Electrolytes, lipids, • Aspirin and CPG complications
bun/cr, • Nitrates • Assess for reperfusion
glucose,coagulation
• Morphin
• CXR
 ECG
Pain relief
-Nitroglyserin if systolic bp >90 mmHg
or/with Morphine 3-5 mg (repeated doses) until pain free

Antiplatelet treatment
160-325mg Acetylsalicylic acid chewed tablet/iv
75-600 mg Clopidogrel according to strategy

STEMI NSTEMI
-Thrombolysis -Early invasive
-PCI strategy
-Conservative or
-Adjunctive
delayed invasive
theraphy strategy
 COMPLICATION

Sudden Death

Arrhythmia (VT/VF) Ventricular Dysfunction (Heart Failure)

Interventricular septum and myocardial wall rupture

Hemodynamic Disturbances

Cardiogenic shock
“
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