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Stemi (ST Elevation Myocardial Infarction)
Stemi (ST Elevation Myocardial Infarction)
Past history:
history of chest pain on and off since 1 month ago
History of hypertension since 5 year ago
History of heart disease is none
History of Diabetes since 2 years ago
HISTORY TAKING
Personal Life History :
There is history of smoking
No history of alcohol consumption
No history of heart disease in the family
No history of diabetes in the family
Past Treatment History :
No history of hospital admission
Physical Examination
General state:
Moderate Illness/ Well nourished/Conscious
Body Weight : 70 kg
Body Height : 175 cm
Body Mass Index : 22,8 kg/m2
Vital state
Blood Pressure : 150/90 mmHg
Heart Rate : 82 x/mnt
Respiratory Rate : 24 x/mnt
Body Temperature: 36,5 °C
Physical Examination
Head :Normochepalic
Eye :Anemis (-), Icteric (-)
Pupil :Equal, round, diameter 2,5 mm, reactive to light
Nares :Appearent is normal
Lip :No cyanosis
Neck :JVP R+2 CmH2O, no lymphadenopathy, no
thyroid enlargement
Physical Examination
Chest Examination
Inspection : Symmetry left = right
Palpation : Mass (-), tenderness (-),
Percussion :Sonor left=right;
Lung-liver border in ICS VI anterior
Auscultation : Breath sound : vesicular
Additional sound : ronchi -/- ; wheezing -/-
PHYSICAL EXAMINATION
Cor :
Inspection : ictus cordis visible
Palpation : ictus cordis palpable, thrill (-)
Percussion :
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea axillaris anterior sinistra
Auscultation : heart sound I/II pure, regular,
murmur (-)
Physical Examination
Abdominal Examination
Inspection : Convex, following breath movement
Auscultation : Peristaltic sound (+), normal
Palpation : Mass (-), tenderness (-), no palpable
liver and spleen
Percussion : Timpani (+), Ascites (-)
Extremities examination
Pretibial edema -/-
Dorsum pedis edema -/-
ELECTROCARDIOGRAPHY
Sinus rhytm
HR : 70 bpm
Regularity: iregular
Axis : normoaxis
PR interval : 0.16 s
QRS rate : 0.08 s
QRS complex : VES
trigemini
ST segmen :
ST segmen elevation
on lead II,III,aVF
Conclusion :
Sinus rhytm, HR : 70
bpm, inferior walls
myocardial infarction,
VES trigemini
LABORATORY RESULTS
TEST RESULT NORMAL TEST RESULT NORMAL
VALUE VALUE
Result :
• Slight Cardiomegaly
with dilatation of
aortae
• Normal Pulmo
DIAGNOSIS
STEMI inferior onset <6 hours, KILLIP I
Hipertension gr.I
Diabetes Melitus Type 2
TREATMENT
Oxygen 2-4 liters per minute via nasal kanula
IVFD NaCl 0,9% 500 cc/24 hours/IV
Aspirin 160mg (loading dose) 80mg/24 hours/oral
Clopidogrel 300mg (loading dose) 75 mg/24 hours/oral
Actilyse : 15 mg bolus iv
50 mg/syringepump in 30 minutes
35 mg / syringepump in 60 minutes
Simvastatin 40 mg/24 hours/oral
Alprazolam 0,5mg/24 hours/oral
Laxadyne syr 10 cc/24 hours/oral
Lovenox 60 mg/12 jam/subcutan
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).
INTRODUCTION
Pathophysiology
RISK FACTORS
Modifiable Non-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
Psychosocial stress old
• Heart disease in biological
Lack of physical activity sister or mother > 65 years old
DIAGNOSIS OF ACS
Ischemic symptoms
CK-MB
Serum cardiac marker
CK
elevations
Myoglobin
ISCHEMIC SYPMTOMS
Prolonged pain (usually >20 mins) – may also be described as a dull pain,
constricting, crushing, squeezing
Usually retrosternal location, radiating to left chest, left arm; can be
epigastric
Not fully relieved by rest or nitroglicerine
Dyspnea
Diaphoresis
Palpitations
Nausea/vomiting
Light headedness
Sense of “impending doom”
ECG CHANGES
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