CASE REPORT

OKTOBER 2015

S TEM I A N TER O S EP TA L <

12 H O U R S O N S ET K ILLIP III
Presented By :
IJMAL
C 111 10 166
Supervisor :
dr. Pendrik Tandean, SpPD-KKV. FINASIM
Department of Cardiology and Vascular Medicine
Medical Faculty of Hasanuddin University
Makassar
2015

PATIEN T ID EN TITY
Name

: Mr. SM

Age

: 60 years old

Address

: Jl. Dirgantara

MR

: 727968

Date of Admission

: 03 Oktober 2015

H ISTO RY TA K IN G
Chief complaint

: Chest pain

Present Illness History :

Left chest pain felt since five hours before admission.

Described as compressed pain and radiating to left arm,

intermittently, duration of pain : > 20 minutes continously

Cold sweating since the night before

Have dyspnea

There was t nausea or vomit

One day before chest pain, the patient went to toraja for
death ceremony of his younger brother

H ISTO RY TA K IN G
Past Illness History :

History of smoking, 2 packs per day since young

No history of hypertension

No history of Diabetes Mellitus

No history of heart attack

No history of chest pain before

No history alcohol consumption

R ISK FA C TO R

Modified Risk Factor

Lack Activity
Smoking

Non-modified risk factor:

Gender : Male
Age : 60 years

P H YSIC A L EX A M IN ATIO N
General Status
Moderate illness / Normal / Conscious
Weight : 70 kg
Height : 170 cm
BMI

: 22,4 kg/m2

Vital Status
Blood pressure
Heart rate

: 88 bpm

Respiratory rate
Temperature

:170/80 mmHg
: 30 rpm
: 36,7 oC

P H YSIC A L EX A M IN ATIO N
Head

: Anemic (-), icterus (-), cyanosis (-)

Neck

: Lymphadenopathy (-), JVP R+2cmH2O

Thorax :

Inspection

: Symmetry left=right

Palpation

Percussion

: Sonor

Auscultation
wheezing -/-

: Vesicular, ronchi diffuse +/+,

: Mass (-), tenderness (-), normal vocal

fremitus

P H YSIC A L EX A M IN ATIO N
Heart

Inspection : ictus cordis not visible

Palpation : ictus cordis not palpable, thrill (-)
Percussion: Dull
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 (-)

PH YSICAL EXAM IN ATIO N

Abdomen :
Inspection : flat and follows breath

movement
Auscultation : Peristaltic sound (+),

normal
Palpation

: Liver and spleen unpalpable

Percussion : Tympani (+), ascites (-)

Extremities :
Edema (-)

Sinus rhythm
Heart rate : 115
bpm
Axis
:
Normoaxis
P Wave
: 0,08
s
PR interval : 0,16
s
Duration QRS :
0,08s
ST segment
:
ST elevation on
lead V1, V2, V3,
V4
ST Depresi Lead 1,
V5, V6

ELECTRO CARD IO G RAPH Y

Conclusion :
Sinus rhythm, HR
113 bpm,
normoaxis, ST
elevation on lead ,

LABO RATO RY RESU LTS

TES T

R ES U LT

N O RM AL
V A LU E

WBC

29,8x 103/uL 4.0 10.0 x 103

R ES U LT

N O RM AL
V A LU E

GDS

- mg/dL

<140

SGOT

101 u/L

<38

SGPT

53 u/L

<41

RBC

5,57 x

HGB

106/uL
16,1 g/dL

12 18

Ureum

33

10-50

HCT

48,0%

37 48

Kreatinin

1,48

0,5-1,2

PLT

4.0 6.0 x 106

TES T

317 x 103/uL 150 400 x 103

Troponin T

<0,05

PT

9,9

10 - 14

CK

612,0

<190

APT

23,4

22,0 - 30,0

CKMB

57,1

<25

Kol Tot

211

200

Natrium

147

136 - 145

Triglisrd

110

200

LDL

174

Kalium

5,4

3,5 - 5,1

< 130

HDL

42

Klorida

114

97 - 111

>55

Asam Urat

3,4-7,0

CH EST X-RAY
Result :
Cardiomegaly
(CTI index :
0.61)
Pulmonary
edema

D IA G N O SIS

ST Elevation Myocardial Infarction

(STEMI) Anteroseptal onset <12
hours, KILLIP III

TR EATM EN T

Bed rest
O2 2-4 lpm via nasal cannula
IVFD NaCl 0,9% 500 cc/24 hours/IV
Aspilet 80 mg/24 jam/oral
Clopidogrel 75 mg/24 jam/oral
Farsorbid 1 mg/jam/syringe pump
Furosemid 200 mg/ 24 jam/syringe pump
Simvastatin 40 mg/ 24 jam/oral
Captopril 12,5 mg/8 jam/oral
Arixtra / 24 jam/sc

P LA N N IN G
ECHOCARDIOGRAPHY
CORONARY ANGIOGRAPHY

D ISCU SSIO N

IN TR O D U C TIO N
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

IN TR O D U C TIO N

AN G IN A
Typical Angina

Substernal chest discomfort of characteristic quality and duration

Provokated by exertion or emotional stress
Relieved by rest and/or GTN (Nitrogliserin)

Atypical
Meet two of thesee characterr

Unstable
Angina
Non
occlusive
thrombus
Non specific
ECG
Normal
cardiac
enzymes

NSTEMI

Occluding
thrombus
sufficient to cause
tissue damage &
mild
myocardial
necrosis
ST depression +/T wave inversion
on
ECG
Elevated cardiac
enzymes

STEMI
Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms

Pathophysiology

CORONARY ARTERY DISEASE

Pathophysiology

ATH ERO SCLERO SIS O F CO RO N ARY

ARTERY

R ISK FA C TO R S

Modifiable

NonModifiable

Smoking

Gender & Age

Hypertension

Men > 45 years

old
Women > 55 years
old

Diabetes mellitus
Hypercholesterole
mia
Obesity
Psychosocial stress
Lack of physical
activity

Family history

Heart disease in
biological brother or
father > 55 years old
Heart disease in
biological sister or
mother > 65 years old

Prolonged chest pain

Usually retrosternal location
Dyspnea
Diaphoresis

Troponin-T
CK-MB
CK
Myoglobin

Serum
cardiac
marker
elevations
Diagnostic
ECG
changes
Ischemic
symptoms

W H O D IA G N O STIC
C R ITER IA

1. ISC H EM IC SYM P TO M S

2. EC G C H A N G ES

Hyperacute
Phase

Complete
Evolution

Non specific STElevation

T taller and wider

Specific STElevation
T inverted
Q-Pathologic

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

3. Serum Cardiac M arker Elevation

CK

CK-MB
Troponi
nT

CARDIAC BIOMARKERS

D iagnosis
Signs of myocardial
ischemia
ECG
ST segmen
elevation ?

No

Lab

Biochemical cardiac
markers ?

No

Yes

Yes

STEMI
Acute Myocardial
Infarction
( Q-wave, non-Q wave )

NSTEMI
(No ST-Segment
Elevation
Myocardial Infarction)

Unstable Angina

G O A L O F TR EATM EN T

Relieve pain

Hemodyna
mic
stabilization

Myocardial
reperfusion

Prevent the
complicatio
n

IN ITIA L TR EATM EN T
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%.

IN ITIA L TR EATM EN T
Morphine 2-5mg iv (can be administered again in

5-30 minutes later)

Fibrinolytic therapy:
Streptokinase 1.5million units iv
Tenecteplase 0.5mg/kg body weight iv

Anticoagulation therapy:
Low Molecular Weight Heparins (Fondaparinux)

2.5mg/24hrs/sc for up to 8 days post-MI.

Unfractionated heparin : Bolus 60units/kg body

weight (maximum 4000U), infuse 12units/kg

body weight/hour (maximum 1000U/hour)
Anti Hypertension Drugs
Lipid Lowering Agents

C O M P LIC ATIO N S

Ventricular
dysfunction

Hemodyna
mic
disturbance
s

Cardiogenic
shock

Arrhythmia

PR O G N O SIS
K ILLIP C LA SSIFIC ATIO N
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