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BAB III

ANALISIS KASUS

The patient came with chest pain since 8.5 hours before arrived at hospital. Chest pain
was occured suddenly. Previously, he had never have a complaint of chest pain. The chest
pain felt by the patient when he was gardening in the woods. The pain was like being
supressed and penetrated to the back but did not spread to the left arm. The pain was felt for
more than 20 minutes and was not relieved by having rest. The chest pain was accompanied
by sweating, shortness of breath, and palpitations. Patients also complain of nausea and
vomiting one colored foods and drinks. Complaints of fever (-), cough (-), appetite and
drinking well, dizziness (+). Bowel and bladder had no complaints.
The patient had a history of hypertension, but did not control routinely since last year.
History of diabetes mellitus and heart disease is denied. The patient had a history of smoking
habit as much as 1 pack per day for 40 years. However, the patient admitted that he had
never smoked for almost two years.
The results of the examination and the general state of the patient's vital signs was
compost mentis, looked in pain due to chest paint, bood pressure 125/60 mm Hg, respiratory
rate 23x / min, 62x pulse / min, 62x heart rate / min, and O2 pulse oxygen saturation with
rooms oxygen 98%.
The chest pain experienced by the patient was one of the clinical presentation typical
of Acute Coronary Syndrome (ACS) in which the patient suddenly felt chest pain precordial
or shortness of breath which is described as a sensation that like being compressed, crushed,
or suppressed, retrosternal with or without radiation to the neck , jaw, left shoulder and left
arm. Pain is usually severe enough, causing activation of the sympathetic nervous system
including nausea, vomiting, and sweating.
In addition, it was found that risk factors may favor the occurrence of ACS, patients
aged over 45 years, male, with a history of smoking, and high blood pressure.
To determine the exact diagnosis, then we did an ECG on the patient. From ECG we
obtained: Sinus rhythm, HR 60 bpm, LAD, with ST elevation in leads II, III, aVF, V3R-V5R
showing the location of infarction in the inferior and RV. While in the examination of cardiac

enzymes troponin I values obtained 1.58 ug / L and CKMB 80.73 ng / mL. There was an
increase in the level of Troponin I and CKMB.
The presence of typical chest pain, description of ST elevation in leads II, III, aVF,
V3R-V5R on an ECG, with an increase in Troponin I and CKMB directing the diagnosis for
inferior and RV STEMI.
When he came in dr. Moewardi, the patient was given oxygen 3lpm using a nasal
cannula. The function of oxygen was to deliver oxygen to tissue, in this case, to the heart
muscle due to chest pain felt by patient with Acute Coronary Syndrome (ACS) caused by
hypoxia in heart muscle.
STEMI, or ST elevation myocardial infarction is the death of heart muscle caused by
total blockage of blood vessels in the heart. According PERKI 2015, it was important to give
both PCI reperfusion therapy (primary percutaneous intervention) or by pharmacological
(thrombolytic) due to the condition of deep vein thrombosis that was an emergency condition
that can cause death of the heart muscle. Acute occlusion conditions that must be eliminated
as soon as possible to save heart muscle tissue that had not died and stop the progression of
tissue death.
Mechanism of action of thrombolytic drugs through the conversion of an inactive
zymogen plasmin (plasminogen) into a fibrinolytic enzyme (plasmin). Plasmin has a weak
specificity to fibrin and can perform degradation of some proteins that have ties arginyl-lysyl
such as fibrinogen. Therefore plasmin may cause fibrin (nogen) lysis (systemic lytic state)
that cause systemic bleeding tendency. In the development of thrombolytic agents, there were
second generation thrombolytic drugs that have specific properties of the fibrin which works
on the surface of fibrin. Plasmin only works on the fibrin clot through the barriers alpha2antiplasmin. Fibrinolytic recommended for patients with acute myocardial infarction <12
hours have ST-segment elevation or left bundle branch block (LBBB) was given IV
fibrinolytic if there was contra-indications.
Patients diagnosed with STEMI onset 8.5 hours. There were not contraindication
(trauma, hemorrhage, and surgical history is less than 2 weeks) so that the patient is given
fibrinoltik immediately.

In patients who received fibrinolytic therapy should also be given antiplatelet.


Aspilet with aspirin as active ingredients, including one that is recommended to be given
antiplatelet after fibrinolysis, and combined with Clopidogrel as ADP receptor inhibitors.
In STEMI patients given antiplatelet also recommended anticoagulation (Perki, 2015).
In this case the patient is given treatment at the injection Arixtra on ICVCU. Arixtra is an
anticoagulant with active ingredient sodium fondanparinux who works as a selective inhibitor
of factor Xa bound prothrombin. Neutralization of factor Xa interfere with the chain of
coagulation and inhibits thrombin formation and thrombus formation. Small molecular size
so that it does not stimulate the activity of thrombin enzimatika to factor IIa (thrombin) or to
other plasma proteins so it does not affect platelet function. Thus, the risk of hemorrhage as a
result of drug administration is minimal compared to other anticoagulants. Fondanparinux
proposed use as an anticoagulant if fibrinolytic used previously is streptokinase. If
fibrinolytic used instead of streptokinase (tenekteplase, alteplase, danreteplase), then
anticoagulation is recommended that become active ingredient enoxaparin Lovenox
Nitrates (isosorbide dinitrate) in patients with vascular dilatation effect aimed to
reduce preload and end diastolic volume of the left ventricle so that reduced myocardial
oxygen consumption, besides nitrate has the effect of dilating the coronary arteries that are
still good and the experience of atherosclerosis.
Pemberian nitrat (Isosorbid dinitrat) pada pasien bertujuan untuk efek dilatasi
vaskuler yang dapat mengurangi preload dan volume akhir diastolic ventrikel kiri sehingga
sehingga konsumsi oksigen miokardium berkurang, selain itu nitrat memiliki efek dilatasi
pembuluh darah koroner yang masih baik maupun yang mengalami arterosklerosis.

Captopril is an angiotensin converting enzyme inhibitor (ACE) -1 useful for reducing


remodeling and reduce mortality of patients (Perki, 2015).
Atorvastatin is a statin given useful for lowering cholesterol levels regardless of the
initial value of LDL cholesterol. Besides lowering the amount of low-density lipoprotein
cholesterol (LDL) in the blood, statins have pleiotropic effects such as improving endothelial
function, reduce inflammatory effects, and reduce thrombus formation. Atorvastatin is a
statin given useful for lowering cholesterol levels regardless of the initial value of LDL
cholesterol. Besides lowering the amount of low-density lipoprotein cholesterol (LDL) in the

blood, statins have pleiotropic effects such as improving endothelial function, reduce
inflammatory effects, and reduce thrombus formation.
To the post-attack patients who required bedrest total, there are likely to occur is
difficulty to defecate due to the effect of prolonged immobilization that get laxatives
(Laxadyn) to an excretion system of the patient. In addition, cardio patients are not allowed
to push to reduce the pressure and burden on the heart, thereby reducing the risk of
complications of heart failure.
In addition to pharmacological therapy given to patients, it is important to educate
patients on complete bed rest during the initial treatment when the patients still had
complaints of chest pain, the goal is to reduce the O2 demand