ST Elevation Myocardial

Infarction

Created by:
Suriyanti Listin (C11109295
Supervisor:
DR. dr. IDAR MAPPANGARA, SPPD, SPJP,
FIHA
CARDIOLOGY DEPARTMENT
MEDICAL FACULTY OF HASANUDDIN UNIVERSITY
MAKASSAR 2014
Patient Identity

 Name : Mr. Bs
 Age : 62 years old
 Gender : male
 Address : BTN Minasaupa
 Medical Record : 651823
 Date of Admission: February 20th, 2014
History Taking
CHIEF COMPLAIN
Chest Pain

PRESENT ILLNESS HISTORY

Left chest pain felt since 4 days ago and felt the last 2 days
before hospital admission, such as burning and pain radiating
to the left arm. Duration ± 10 minutes and felt at rest. Cold
sweat (+) and a sense of palpitations (+) especially when chest
pain. Dizziness (-) and headache (-). Cough (-) and mucus (-).
Shortness of breath (-), previous history of shortness of
breath (-). Nausea (-), vomiting (-), heartburn (-). Normal
urination and defecation
 Previous Illness History
History of diabetes mellitus (-)
History of hypertension (-) since 2 years ago and took
medicine Iregularly
History of dyslipidemia (-)
History of smoking (+)
History of chest pain before (-)
History of heart diseases (-)
Family history with heart disease (-)
Risk Factors
Modifiable Risk Non-modifiable
Factor Risk Factor

Diabetes
Female
Mellitus

> 60
years old
Physical Examination
GENERAL
APPEARANCE
- Moderate Illness/Well Nourished/ Composmentis
- Body Weight : 50 kg
- Body Height : 150 cm
- Body Mass Index (BMI) : 22.2 kg/m2

VITAL SIGN
– BP : 160/90 mmHg
– HR : 80 x/min
– RR: 16x/min
– T : 36.70 C
 REGIONAL STATE
 Head Examination
- Eyes : Anemis -/-, icterus -/-
- Lip : Cyanosis (-)
- Neck : JVP R -1 cmH2O
 Chest Examination
- Inspection : Symmetric right = left, normochest
- Palpation : No mass, no tenderness
- Percussion : Sonor, lung-liver border in ICS VI right
anterior
- Auscultation : Breath sound : Vesicular
Additional sound : Ronchi -/-
wheezing -/-
  Cardiac Examination
- Inspection : Ictus cordis invisible
- Palpation : Ictus cordis impalpable
- Percussion : Right heart border in right parasternal
line, left heart
border in left midclavicle line ICS V
- Auscultation : Regular of I/II heart sound, no murmur
 Abdominal
- Inspection : flat, following breath movement
- Auscultation : Peristaltic sound (+), normal
- Palpation : No mass, no tenderness, liver and spleen
unpalpable
- Percussion : tymphani, ascites (-)
 Extremities
- Oedema pretibial -/-
- Oedema dorsum pedis -/-
Continue…
Chest X-Ray (19/1/2014)
 Result

Dilatation et elongation
aorta and sign of lung
congestion
ECG (19/1/2014)

• Rhythm : Sinus Rhythm

 Heart Rate : 100 x/ minute
 Axis : Normoaxis
 P Wave : 0.08 s
 PR Interval : 0.12 s
 QRS Duration : 0.06 s
 ST Segment : ST Elevasi lead
I, aVF, V5-V9
 T inverted :Lead
II,III,aVF,V5-V9
Result : Sinus Rhythm, Heart Rate
100x/minute, Normoaxis, Inferior et
posterior infarction
Laboratory Findings (19/1/2014)

Complete Blood Count

Test Result Normal
value
WBC 17,8 x 103/uL 4.0 – 10.0 x
103
RBC 4,61 x 106/uL 4.0 – 6.0 x
106
HGB 13,7 g/dL 12 – 16
HCT 41,4% 37 – 48
PLT 382x 103/uL 150 – 400 x
103
 Continue…
Blood Chemistry &
Cardiac Enzymes
Tes Hasil Nilai Normal
GDS 98 mg/dL <140
SGOT 142 u/L <38
SGPT 43 u/L <41
Ureum 41 10-50
Kreatinin 1,2 0,5-1,2
Kolesterol total 231 mg/dl 200
Kolesterol HDL 32 mg/dl L(<55) P (<65)
Kolesterol LDL 174 mg/dl <130
CK 1399 L (<190), P (<167)
CK-MB 88,9 <25
Troponin T 0,92 <0,05
 Working Diagnosis

Inferior Posterior
ST Elevation Myocardial Infarction
Onset > 24 hours KILLIP I
Therapy
 O2 4 lpm via nasal canul
 IVFD Nacl 0,9 % 500 cc/24 hour
 Anti-Platelet: Aspilet 80 mg (loading dose 2x80 mg)
Clopidogrel 75 mg (loading dose 4x75 mg)
 Nitrat: Farsorbid 5 mg/SL(K/P)
Farsorbid 10 mg 3x1
 Statin: Simvastatin 1x 20 mg
   ARB (Angiotensin Receptor Blocker) : Valsartan 1x80
mg
 Anti-anxietas: Alprazolam 0,5 mg 0-0-1
 Laxative: Laxadyn syr 0-0-2 C
Planning
Echocardiography
Angiography
Discussion

Acute Coronary Syndrome

(ST Elevation Myocardial Infarction)
 Definition :
Acute Coronary Syndrome (ACS) is a term for situations
where the blood supplied to the heart muscle is suddenly
blocked.
 describe 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).
Classification:
 Non-Modifiable Modifiable

Gender and Age Smoking

Hypertension
Family History

Diabetes Melitus

Dyslipidemia

Risk Factors Obesity

 Diagnosis of ACS
At least 2 of the following :

1. Ischemic symptoms

2. Diagnostic ECG changes

3. Serum cardiac marker elevations

1. Ischemiac Symptoms
• Duration of chest pain > 20 minutes, at substernal area
• Substernal chest pain / chest discomfort radiated to the left arm,
shoulder, neck, jaw
• Not fully relieved by rest or nitroglycerine

• The chest discomfort may also be described as a dull

pain ,‘pressure’, ‘squeezing’ or ‘crushing sensation’ or burning
sensation

• Associated features including palpitation, sweating,

breathlessness, and nausea.
2. Diagnostic ECG Changes
3. Serum Cardiac Marker Elevation

CK CK-MB

Troponin
T
 Diagnosis
Signs of myocardial ischemia

ECG
Yes STEMI
ST segmen elevation ? Acute Myocardial Infarction
( Q-wave, non-Q wave )

No Lab
Yes
Biochemical cardiac markers ?
NSTEMI
(No ST-Segment Elevation
Myocardial Infarction)
No
Unstable Angina
Therapy
 Bed rest
 Diet
 O2 2-4 lpm via nasal prongs
 Nitrat:
 ISDN 10 mg or 20 mg, 2-3 a day.
 ISDN 5 mg SL when chest pain.
 Antiplatelet:
• Aspirin 160-325 mg chewed immediately and 80-160 mg
continued indefinitely.
• Clopidogrel 300-600 mg loading dose and 75 mg daily continued
 Trombolitic: (if onset < 6 hours)
1,5 million unit IV in a hour
Prognosis
KILLIP CLASSIFICATION

Class Description Mortality Rate

(%)
I no clinical signs of heart failure 6
II rales or crackles in the lungs, an S3, 17
and elevated jugular venous pressure
III acute pulmonary edema 30 - 40
IV cardiogenic shock or hypotension 60 – 80
(systolic BP < 90 mmHg), and
evidence of peripheral
vasoconstriction
TIMI PROGNOSIS
Risk Factor Score
Age > 65 years old 2 Risk of
Total
  >/= 75 3 Death in 30
Score
days
History of 1
0 0.8%
angina/hipertension/DM
1 1.6%
2 2.2%
Systolic BP <100 3
3 4.4%
Heart rate >100 2 4 7.3%
Killip II-IV 2 5 12.4%
Weight >67 kg 1 6 16.1%
Anterior MI or LBBB 1 7 23.4%
8 26.8%
Delay treatment >4 hours 1
9-14 35.9%