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Medical Faculty
Hasanuddin University
Case Report
April 2013
STEMI Inferior
Case Report >24 Jam
Onset
Killip II
Austein Wedyanto
C 111 08 346
Supervisor:
dr. Muzakir Amir, Sp.Jp.FIHA FICA
HASANUDDIN UNIVERSITY
MAKASSAR
2013
Patients Identity
Name
Mr. D
Gender
Male
Age
69 years old
Address
Riso Enrekang
599669
Date of Admission
History Taking
Chief Complain
: Chest Pain
Previous Illness
Physical Examination
General status:
Moderate Ilness/ Overweight/Conscious (Alert and
Oriented)
Body Weight
: 60 kg
Body Height
: 165 cm
Body Mass Index
: 22,8 kg/m2
Vital Status
Physical Examination
Head :
Normochepalic
Eye :
Anemis (-), Icteric (-)
Pupil :
Equal, round, diameter 2,5 mm,
reactive to light
Nares:
Appearent is normal
Mouth
:
No cyanosis
Neck :
JVP +3 CM H2O, no lymphadenopathy,
no thyroid enlargement
Physical Examination
Lung
Inspection
Palpation:
Percussion
Auscultation
:
Equal expension bilaterally
No tenderness, no mass palpable
:
Normal resonance bilaterally
:
Breath Sounds
: Vesicular
Adventitious breath sound
: Ronchi (-) , No
wheezing
Physical Examination
Cardiac Examination
Inspection : Ictus cordis was invisible
Palpation : Ictus cordis was palpable in ICS V
about 1 finger from lateral of medioclavicularis
sinistra line, Thrill (-)
Percussion : Right heart border in right
parasternalis line, left heart border in left
midclavicle line ICS V.
Auscultation
: Heart Sounds = S I/II regular.
Physical Examination
Abdominal
Extremities
Oedema pretibial -/ Oedema dorsum pedis -/ Cyanosis (-), Clubbing finggers (-)
ECG Finding
(18/03/2013)
Rhythm
: Junctional rhythm
P wave
: Invisible P wave
Heart Rate
: 72/minutes
Duration QRS
: 0,06 s
Axis
: 105 Degree
ST Segment
: ST Elevation at Lead II,III,
AVF. ST depresi at AFL, Lead I, V4, V5, V6
T wave
: T Inverted Lead II, III, AVF
CONCLUSION :
1. Junctional Rhythm
2. STEMI Inferior
Laboratory Findings
1/03/13
WBC
13,09 x 103
Na
142
RBC
5,27 x 106
4,7
HGB
15,3
Cl
107
HCT
46,5%
PT
11,3
PLT
204
APTT
26,5
Ur
67
GDS
111
Cr
1,3
SGOT
816
CKMB
675
SGPT
135
Trop T
>2,0
Echocardiography
findings
LV systolic function
decrease, EF 42%
Dilated LA and LV
Hypokinetic at Inferior,
inferoseptal and inferior
No LVH
RV Function decrease,
TAPSE 0,9 cm
Mpa 30 mmHg
Heart valves :
Mitral : MR Mild
Aorta : no calcification
Trikuspid : TR Mild
Pulmonal : function and
motility are good
Conclusion :
1. Diastolic and
systolic of both
ventricle
disfunction
2. Hypokinetic at
Inferior,
Inferoseptal and
posterior
3. MR, TR, PH
Mild
Working Diagnosis
STEMI Inferior onset > 24Hours Killip II
HT Grade I
Therapy
Bed Rest
O2 3 4 liter/min via nasal canule
Heart Diet
IVFD NaCl 0,9% 1000cc/24 hours
(Salysilic Acid) Aspilet 80 mg 1-0-0
(Clopidogrel) Plavix 75 mg 0-1-0
(ACE Inhibitor) Captopril 25 mg 1-0-1
(Statin) Simvastatin 20 mg 0-0-1
(Fondaparinux sodium) Arixtra 2,5 mg/24 hours/SC
(Isosorbide dinitrate) Cedocard 5mcg/minutes via
syringe pump
Alprazolam Tab 0,5 mg 0-0-1
(Bisacodyl)Laxadyn syrup 0-0-2
Management
Planning
ECG Control
Coronary angiography
Discussion
STELEVATIONMYOCARDIAL
INFARCTION
DEFINITION
Myocardial infarction (MI)
rapid
development
of
myocardial necrosis caused by a
critical imbalance between the
oxygen supply and demand of
the myocardium.
This usually results from plaque
rupture
with
thrombus
formation in a coronary vessels,
resulting in an acute reduction
of blood supply to a portion of
the myocardium.
PATHOPHYSIOLOGY
Occurs when
CLASSIFICATION
RISK FACTORS
Non- Modifiable
Gender and Age
Men, increased risk after age
Modifiable
Smoking
Hypertension
45
Women, increased risk after
age 55
Family History
Diabetis Mellitus
Dyslipidemia
Obesity
Lack of physical
activity
CLINICAL FEATURES
1. Chest pain, >30 minutes
2. Usually tight, crushing, and
band like
3. Location in retrosternal
4. May radiate to left arm, throat,
and jaw
5. Associated features including
palpitation, sweating,
breathlessness, and nausea.
Diagnosis
Signs of myocardial
ischemia
ECG
Yes
ST segmen elevation ?
No
Acute Myocardial
Infarction
(STEMI)
Lab
Yes
NSTEMI
( Non ST-Elevation
Myocardial Infarction )
No
Unstable
Angina
Complication
Myocardial rupture
Arrhythmia
Cardiogenic shock
Pericarditis
Therapy
Managing chest pain and anxiety
o Bed rest
o Diet
o O2 2-4 lpm
o Nitrate sublingual/oral/IV
o Antiplatelet: aspirin and clopidogrel
o Morphine/ pethidine
Stabilizing hemodynamic
(blood pressure and peripheral pulse control)
o -blocker
o Calcium channel blocker (CCB)
o ACE-Inhibitor
Reperfusion of the myocardium
o Thrombolytic
Score
2
History of
angina/hypertension/DM
1/1/1
Systolic BP <100
2
2
1
1
Delay treatment
>4hours
Total Score
0
1
2
3
4
5
6
7
8
9-16
Risk of Death in 30
days
0.8%
1.6%
2.2%
4.4%
7.3%
12.4%
16.1%
23.4%
26.8%
35.9%
PROGNOSIS KILLIP
CLASSIFICATION
Mortality Rate (%)
Class
Description
6
I
no clinical signs of heart
failure
II
rales or crackles in the
17
lungs, an S3, and elevated
jugular venous pressure
III
IV
30 - 40
60 80
Thank You