CASE PRESENTATION:

ST ELEVATION MIOCARD INFARK whole

anterior onset >24 hours killip 4

PRESENTED BY:
FIKRI RIFA HAMDI
SUPERVISOR PEMBIMBING:
PROF. DR. DR. ALI ASPAR M, SP.PD, SP.JP(K), FIHA, FINASIM

Patient identity
Name

: Mr. H

Age

: 57 years old

Registration no.

: 566506

Room

: CVCU

History taking
Chief Complain
Left chest pain
Present illness history
Suffered since 1 day ago
This pain was suddenly
Described as intermittently compressed, through to the back, pain
accompanied with cold sweating
No epigastric pain
No DOE, PND and orthopnea
History of smoking since 10 years ago with 10-12 cigarettes per day

History of Past Illness

History hospitalized with heart attack on July 2014

History of diabetes since 2 years ago and treated regularly

History of hypertension denied

No history of heart disease in the family

PHYSICAL EXAMINATION
General condition

Vital Signs

Moderate illness/well-nourished/conscious
(GCS 15: E4M6V5)

BP : 80/50 mmHg
HR : 100 x/minutes
RR : 24 x/minutes
T : 36.7 oC

Head

Anemis (-) , icterus (-)

Neck

JVP R + 2 cmH20

Chest
Examination

Cor

I : symmetric R=L, normochest

P : mass (-), tenderness (-), VF R=L
P : sonor
A : breath sound : vesicular additional
sound : ronchi minimal at base of lung , wh
-/-

I
: ictus cordis not visible
P : ictus cordis not palpable
P : dull, Upper border 2nd ICS sinistra, Right
border 4th ICS linea parasternalis dextra, Left
border 5th ICS linea axillaris anterior sinistra
A : HS I/II pure, regular, murmur(-)

Abdomen :

Inspection : flat and correspond with breathing movement

Auscultation
: peristaltic sound (+) , normal
Palpation : liver and spleen impalpable, epigastric pain (-)
Percussion : tympani, ascites (-)

Extremities:
Edema -/-

PEMERIKSAAN

7-3-2015

HASIL

NORMAL

WBC

15,4 x 103/mm3

4.0-10.0 x 103

RBC

5,71 x 106/mm3

4.0-6.0 x 106

HGB

18 gr/dL

12-16

HCT

52%

37-48

PLT

248 x 103/mm3

150-400 x 103

Ureum

63

10-50 mg/dl

Creatinin

1,4

0.5-1.2 mg/dl

SGOT

22

<35 U/L

SGPT

36

<45 U/L

Na

136

136-145 mmol/l

3,9

3.5-5.1 mmol/l

Cl

107

97-111 mmol/l

GDS

223

200 mg/dl

CK

753

L(<190U/L) P(<167U/L)

CK-MB

14,3

<25U/L

Troponin T

<0,1

<0,05

Kolesterol total

108

200 mg/dl

Asam urat

6,8

L 3,4-7,0 ; P 2,4-5,7

HDL

18

L>55; P>65

ELECTROCARDIOGRAPHY (7-3-2015)
Sinus rhytm
HR
Axis
PR-Interval
P-Wave
QRS Duration
ST-segment

: 110 bpm
: normoaxis
: Normal
: Normal
: 0,08 minute
: elevation on V1-V6

Conclusion
Sinus rhytm, normoaksis, whole anterior miokard
infark

ECHOCARDIOGRAM
Disfunction systolik ventrikel
EF 41%
Left Ventricular Hipertrophy
Mild hipokinetik anterior, anteroseptal and anterolateral
Cardiac valve :

Mitral : good function and movement

Aorta : calsification
Tricuspid: good function and movement
Pulmonal : good function and movement

Conclude :

Disfunction systolik and diastolik LV

Left Ventricular Hipertrophy

Risk Factor

Modified Risk Factor

Diabetes
Smoking

Non-modified risk factor:

Gender : male
57 years old

Diagnosis
ST Elevation Myocardial Infarction

(STEMI) whole anterior onset >24 hours,

Killip 4
DM type 2
Syok Cardiogenic

Treatment management
O2 2-4 lpm via nasal kanul
IVFD NaCl 0.9% 500 ml/24 hours
Anti Platelet Aggregation:

Aspilet (loading dose 325 mg) maintenance 1x80 mg

Clopidogrel (loading 600 mg) maintenance 1x75 mg

Anti Angina:

Pethidine 12,5 mg/24 hours extra, maintenance 100mg/24 hours/drips

Anti Coagulant:

Lovenox 0,6 cc/24 hours/SC

Simvastatin 20 mg/24 hours/oral

Dobutamin 5 mcg/ kgBB/minute/syringe pump
Laxadin syrup 15 ml/ 24 hours/ oral
Primary PCI

PLANNING

Coronary angiography

How to make
the diagnosis?

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).
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.

 Occurs when coronary blood flow

decreases
abruptly
after
a
thrombotic
occlusion
of
a
coronary
artery
previously
affected by atherosclerosis.
In most cases, infarction occurs
when
an
atherosclerotic
plaque fissures, ruptures, or
ulcerates.

Diagnosis Of ACS
At least 2 of the following (WHO criteria):
Ischemic symptoms
Diagnostic ECG changes
Serum cardiac marker elevations

Diagnosis Of ACS
Prolonged chest

At least 2 of the following

Ischemic symptoms
Diagnostic ECG changes

pain (usually >20

minutes)
constricting,
crushing,
squeezing

Serum cardiac marker elevations

Usually
retrosternal
location, radiating
to left chest, left
arm; can be
epigastric
Dyspnea
Diaphoresis

Diagnosis Of ACS
At least 2 of the following
Ischemic symptoms
Diagnostic ECG

changes
Serum cardiac marker

elevations

ECG evolution for MI

Diagnosis Of ACS

At least 2 of the following

Troponin T

Ischemic symptoms
Diagnostic ECG changes
Serum cardiac marker

elevations

CK-MB
CK
Myoglobin

DIAGNOSIS

Signs of myocardial ischemia

ECG
ST segmen elevation?

No

Lab

Biochemical cardiac markers?

No

Yes

Yes

Acute Myocardial Infarction

( Q-wave, non-Q wave )
NSTEMI
(No ST-Segment
Elevation
Myocardial Infarction)
Unstable Angina

Unstable
Angina

NSTEMI

STEMI

Non-occlusive thrombus
Non-specific on ECG
Normal cardiac enzyme markers

Occluding thrombus sufficient to cause tissue damage & mild

myocardial necrosis
ST depression +/ T wave inversion on ECG
Elevated cardiac enzyme markers

Complete thrombus occlusion

ST elevation on ECG
Elevated cardiac enzyme markers
Symptoms more severe

INFARCT LOCATION

KILLIP CLASSIFICATION

Class
I
II

III
IV

Description
no clinical signs of heart
failure
rales or crackles in the lungs,
an S3, and elevated jugular
venous pressure
acute pulmonary edema
cardiogenic shock or
hypotension (systolic BP < 90
mmHg), and evidence of
peripheral vasoconstriction

Mortality Rate (%)

6

17

30 - 40
60 80

GOAL OF TREATMENT

Relieve pain

Hemodynamic
stabilization

Myocardial
reperfusion

Prevent the
complication

COMPLICATIONS

Ventricular
dysfunction

Hemodynamic
disturbances

Cardiogenic
shock

Arrhythmia

Thank you