Myocardial Infarction

with ST segment Elevation

Presented By :
Nor Maisarah Bt Mohamed Shukri
Supervisor :
dr. Pendrik Tandean, SpPD

PATIENT IDENTITY
Name

: Mrs. M
No.MR
: 475376
Age
: 67 years old
Gender
: Female
Date of admittance : 1st August 2011

HISTORY TAKING
Chief complaint: Chest pain
History taking:
Chest pain is felt 8 hours before admitted to the
hospital. Pain felt weighted on her left chest duration
more than 20 minutes, penetrates to the back of the
body and arms. Pain feels such squeezing sensation in
the chest. The pain appeared suddenly after she
prayed and doing house cores. Pain do not improved
by rest.
Sweating (+) , Dyspnea (+), Cough (-)
Nausea (-), vomiting (-)
Epigastric pain (+)
Defecation and urination is normal

PAST ILLNESS HISTORY

History of heart disease (-).
Family history of heart disease (-)
Diabetes mellitus (-)
Hypertension (-)

PHYSICAL EXAMINATIONS
General Appearance :

Moderate-illness/well-nourished/compos mentis

Vital Sign :
Blood Pressure
: 120/80 mmHg
Pulse
: 82 bpm, regular
Respiratory rate : 22 tpm ; thoracoabdominal
Body temperature : 36,7 C (axilla)
Head Examination :
Eyes : anemia(-), icterus(-), cyanosis(-)
Neck : JVP R+2 cmH20
Thoracic Examination :
Inspection : Symmetric left and right
Palpation : No mass, no tenderness
Percussion
: Sonor
Auscultation : Breath Sound : vesicular, Rh -/-, wh -/-

 Cardiac Examination :
Inspection : Ictus Cordis wasnt visible
Palpation : Ictus Cordis wasnt palpable
Percussion : normal heart size
Upper border : left ICS II
Lower border : left ICS V
Right border : right parasternalis line
Left border
: 1 finger lateral of left medioclavicular
Auscultation : Regular of I/II Heart Sound, no murmur
Abdominal Examination :
Inspection : flat and following breath movement
Palpation
: liver and spleen unpalpable
Percussion : Tympani
Auscultation
: peristaltic sound (+) , normal
Extremities :
Oedema pretibial -/-

line

LABORATORY FINDINGS
Complete blood count
WBC:10.38 x 103/ul
RBC: 3.94 x106/ul
HGB: 12.3 gr/dl
HCT: 36.0%
PLT: 271 x103/l
Electrolyte
Sodium:139 mmol/l
Potassium : 3.7 mmol/l
Chloride: 101 mmol/l

Blood chemistry
FPG : 129 mg/dl
Ureum : 36 mg/dl
Creatinine : 0.9 mg/dl
SGOT/SGPT: 35 / 18 u/dl
Cholesterol Total : 268 mg/dl
HDL: 42 mg/dl
LDL: 208 mg/dl
Tg: 72 mg/dl
CK: 652
CK-MB : 77

INTERPRETATION
Rhythm : Sinus
QRS rate

: 80 bpm

Regularity : Regular
PR interval : 0.20 sec
Axis : RAD
Morphology
P wave

: normal
QRS complex : Q waves pathologic in lead V1,V2,V3,V4
ST Segment : Elevation at V1,V2,V3,V4 ,V5, V6, I, aVL
T wave : normal
Interpretation: Sinus rhythm, HR 80 bpm, extensive

anterior MI
Diagnosis: Extensive anterior MI

Thorax Photo
AP:
Cardiomegaly;
CTI = 0.65

ECHOCARDIOGRAPHY
CONCLUSION :

EF 60%
Hipokinetic septal
E/A < 1
Dysfunction distolic grade I

susp CAD

WORKING DIAGNOSIS
STEMI extensive anterior onset

> 6 hours Killip I

TREATMENT
Bed rest
O2 2-4 Lpm
IVFD NaCl 0.9% 10 dpm
Farsorbid 5 mg 1-1-1 SL (when needed)
Farsorbid 10 mg 1-1-1
Aspilet 80mg loading 2 tabs (0-1-0)
Clopidogrel 75mg loading 4 tabs (1-0-0)
Captopril 6,25 mg 1-1-1
Alprazolam 0,5 mg 0-0-1
Laxadin syr 0-0-2 C
Ranitidine 1 amp/12H/IV
Arixtra 2,5 mg/SC/24H
Simvastatin 20 mg 0-0-1

DISCUSSION
Acute Myocardial Infarction

DEFINITION
Myocardial infarction (MI) is the 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 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

In acute coronary syndrome, a coronary

artery plaque erodes or ruptures, leading to

the formation of a blood clot, which blocks
the blood flow.

An area of cardiac muscle damage due

to acute occlusion in a coronary artery

that delivers blood to that area

RISK FACTORS
Age > 45 years old
Male gender
Smoking
Hypercholesterolemia and

hypertriglyceridemia,
Diabetes mellitus
Poorly controlled hypertension
Family history
Sedentary lifestyle

CLINICAL FEATURES
Chest pain, >30 minutes
Usually tight, crushing, and band

like
Location in retrosternal
May radiate to left arm, throat,
and jaw
Associated features including
palpitation, sweating,
breathlessness, and nausea.

Diagnose

ns of myocardial ischemia
ECG

Yes

ST segmen elevation ?

Infarction

( Q-wave, non-Q

wave )

No
Lab
Yes

chemical cardiac markers ?

No

Acute Myocardial

NSTEMI
( No ST-Segment
Elevation
Myocardial

Infarction )

Unstable Angina

In STEMI patients the ST segment is elevated; in

NSTEMI patients the ST segment is not elevated,
and instead other patterns are seen. The most
common characteristics of NSTEMI ECGs are ST
depression and T inversion.

What are cardiac markers?

Cardiac markers are proteins expressed commonly or
exclusively by myocardial cells and released into the circulating
blood upon cell necrosis. They are known as troponin I, troponin
T, myoglobin and CK-MB . These cardiac markers play an
essential role in the global risk assessment and treatment of
patients presenting with an acute coronary syndrome (ACS).

MANAGEMENT
Bed rest
Diet
Oxygen
Aspirin and/or anti platelet agent
-blocker
Nitrates
Trombolitic
ACE inhibitors

LOCALISATION of MI
Anteroseptal
Extensive anterior

aVL
Anterolateral
aVL
Anterior limited
Inferior
High Lateral

: V1-V4
: V1-V6, I and
: V4-V6, I and
: V3-V5
: II, III dan aVF
: I dan aVL

COMPLICATION of MI
Based on KILLIP classification:
Classification

Description

KILLIP I

No crackles, no 3rd heart sound

KILLIP II

Crackles in <50% of the lung

field, or a 3rd heart sound

KILLIP III

Crackles in > 50% of lung field,

lung edema

KILLIP IV

Cardiogenic shock

CONCLUSION
Starts Healthy Lifestyle

Change eating habits

Regular exercise
Stop smoking
Avoid stress

THANK YOU