CASE REPORT

ST Elevation Myocardial Infarction Whole

Anterior et Inferior Onset <12 hour KILLIP III
Presented by:
Ahmed Abrizan bin Hassan
C 111 10 865

Supervisor:
dr. Abdul Hakim Alkatiri, SpJP. FIHA

Patients Identity
Name
: Mr. S
Age
: 54 years old
Address
: Jl. Kumala 2 LR 1
Medical Record
: 693357
Date of admission : 18th December 2014

History Taking
Chief complain: Chest pain
Present illness history:
Chest pain felt 8 hours before admitted to
hospital, happen suddenly when resting.
Described as compressed, burning on the
chest, continuously, but not radiating. Pain
accompanied by dispneu and cold sweating.

History Taking
Past illness history:
History of hypertension since 6 month ago,
didnt take medicine continously
No history of diabetes mellitus
History of chest pain before present
No history of heart disease
History of uric acid since 10 years ago,
didnt take medicine continously

History Taking
Personal life history:
History of drinking alcohol 3 bottles/day
since 35 years ago & stopped 2 years ago
History of smoking since 35 years ago &
stopped since admitted to hospital

Risk Factor
Non modified
Gender: Male

Modified
Hypertension

Age: 54 years old

Uric acid
Smoking
Alcohol

Physical Examination
Head: anemic (-) icteric (-)
Neck : JVP R+1 cmH2O,

Lung :
Inspection
: symmetry left=right
Palpation
: mass (-), no tenderness, normal
vocal
fremity
Percussion
: sonor
Auscultation : vesicular, ronchi +/+, wheezing -/-

Physical Examination

Cor :
Inspection : ictus cordis not visible
Palpation: ictus cordis not 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

Abdomen :

Inspection : flat, follows breath movement

Auscultation: peristaltic (+), normal
Palpation: liver and spleen not palpable
Percussion : tympani

Extremities :
Edema (-)

Electrocardiography

Sinus rhythm
Heart rate : 136
bpm
Axis: Left Axis
Deviation
P Wave: 0,08 s
PR interval : 0,16 s
Duration QRS :
0,08 s
ST segment : ST
elevation on lead
II, III, avF, V2-V6
Conclusion :
Sinus rhythm, HR
138 bpm, left axis
deviation, ST
elevation on lead
II, III, avF, V2-V6
(ST-elevation
myocardial
infarction whole

Laboratory Results
TES
T
WBC

HGB

16,5 x
103/uL
4,43 x
106/uL
12,8 g/dL

NORMAL
VALUE
4.0 10.0 x
103
4.0 6.0 x
106
12 16

HCT

38,5%

PLT

355 x
103/uL
12,2 control
11,1
30,2 control
24,5
1,00

RBC

PT
APTT
INR

RESULT

TEST

RESULT

PPBSL

256 mg/dL

NORMAL
VALUE
<140

ALT

170 u/L

<38

AST

108 u/L

<41

Ureum

33

10-50

37 48

Creatinin

1,20

0,5-1,2

150 400 x
103
10 - 14

Troponin I

10,9

<0,01

CK

2683,00

<190

CKMB

153,5

<25

Natrium

143

136 - 145

Kalium

4,3

3,5 - 5,1

Chloride

106

97 - 111

Uric Acid

8,2

3,4-7,0

22,0 - 30,0

Diagnosis

ST Elevation Myocardial Infarction Whole

Anterior et Inferior onset <12 hours KILLIP
III

Treatments

O2 4 lpm via nasal cannula

IVFD NaCl 0,9% 500 ml/24 hours
Furosemide 40 mg/12 hours/intravenous
Farsorbid 2 mg/hour/syringe pump
Aspilet 80 mg/24 hours/oral
Clopidogrel 75 mg/24 hours/oral
Atorvastatin 40 mg/24 hours/oral
Captopril 12,5 mg/8 hours/oral
Alprazolam 0,5 mg 0-0-1
Streptokinase 1,5 million unit in Dextrose 5% 100
ml finish in an hour

Discussion
Acute Coronary Syndromes
(ACS)

Definition
Definition: a constellation of
symptoms related to obstruction of
coronary arteries with chest pain
being the most common symptom in
addition to nausea, vomiting,
diaphoresis etc.
Chest pain concerned for ACS is often
radiating to the left arm or angle of
the jaw, pressure-like in character,
and associated with nausea and
sweating.

Classification

Based on ECG and cardiac enzymes, ACS is

classified into:
STEMI: ST elevation, elevated cardiac enzymes
NSTEMI: ST depression, T-wave inversion,
elevated cardiac enzymes
Unstable Angina: Non specific ECG changes,
normal cardiac enzymes

Pathophysiology

Pathophysiology

Risk Factors
Modifiable
Smoking
Hypertension
Diabetes mellitus
Hypercholesterolemia
Obesity
Psychosocial stress
Lack of physical activity

NonModifiable
Gender & Age
Men > 45 years old
Women > 55 years old
Family history
Heart
Heart disease
disease in
in biological
biological
or
father
>
55
or father > 55 years
years old
old
Heart
disease
in
biological
Heart disease in biological
or
or mother
mother >
> 65
65 years
years old
old

brother
brother
sister
sister

Diagnosis
Ischemic
symptoms

Prolonged
Prolonged chest
chest pain
pain
Usually
retrosternal
Usually retrosternal location
location
Dyspnea
Dyspnea
Diaphoresis
Diaphoresis

Troponin-T/
Troponin-T/ Troponin-I
Troponin-I
CK-MB
CK-MB
CK
CK

Diagnostic ECG
changes
Serum cardiac
marker
elevations

ECG CHANGES

Hyperacute
Phase

Complete
Evolution

Non
Non specific
specific STSTElevation
Elevation
T
T taller
taller and
and wider
wider

Specific
Specific STSTElevation
Elevation
T
T inverted
inverted
Q-Pathologic
Q-Pathologic

Old Infarct
Q-Pathologic
Q-Pathologic
ST
ST segment
segment
isoelectric
isoelectric
T
T normal
normal or
or
inverted
inverted

CARDIAC BIOMARKERS

Treatments
Reperfusion therapy is reasonable for patients with
STEMI and symptom onset within the prior 12 to 24
hours who have clinical and/or ECG evidence of
ongoing ischemia. Primary PCI is the preferred
strategy in this population
Reperfusion therapy:
Primary Percutaneous Coronary Intervention (PCI).
Goal: door to balloon 90 minutes
Fibrinolytic Therapy using fibrinolytic agents such
as Streptokinase 1.5 million unit intravenous
(administered within 30 minutes of hospital
arrival)

Treatments

Bed rest
Oxygen (2-4 lpm)
Anti platelet therapy :
Aspirin 162-325mg chewed immediately and 81-162
mg continued indefinitely.
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%.

Treatments

Morphine 2-5mg iv (can be

administered again in 5-30 minutes
later)

Anticoagulation therapy:
Low Molecular Weight Heparins (Fondaparinux)
2.5mg/24hrs/sc for up to 8 days post-MI.
Unfractionated heparin

Anti Hypertension Drugs

Lipid Lowering Agents

Complications

Prognosis
KILLIP Classification
Class

Description

Mortality rate
(%)

No clinical signs of heart failure

II

Rales or crackles in the lungs, an S3, and

elevated jugular venous pressure

17

III

Acute pulmonary edema

30-40

IV

Cardiogenic shock or hypotension (systolic

BP < 90 mmHg), and evidence of peripheral
vasoconstriction

60-80

Thank You!