CARDIOLOGY

DEPARTMENT
MEDICAL FACULTY
HASANUDDIN
UNIVERSITY

CASE REPORT
December 2013

Inferior Wall ST Elevation

(STEMI)
Onset 12 Hours Killip I

BY :
ANITA HS PAREWASI (C 111 09 103)
SUPERVISOR:
dr. Juzny Alkatiri, Sp.PD, Sp.JP. FIHA

Patient Identity

Name
Age
Gender
Address
Wajo
Medical Record
Date of Admission

:
:
:
:

Mr. H
79 Years Old
Male
Udang street, Kab.

: 643042
: December 22nd, 2013

History Taking
Chief

Complaint : Chest Pain

History Taking : Experienced since 8 hours
before admission to the hospital. The patien feel
like pressed by heavy object on the left of the
chest. The pain radiated to right arm. The
duration of the pain was more than 10
minutes.Early, he felt pain after while during
activity in his garden. Cold sweat (-), breathing
difficulty (-), cough (-), fever (-), history of fever
(-), nausea (-), vomit (-), epigastric pain (-)
Urination via cateter and defecation normal.

History of Previous Illness

History of heart disease (-)
History of hypertension (+) since 10 years
ago, on treatment
History of diabetes mellitus (-)
History of dyslipidemia (-)
Family history with heart disease (-)

Risk Factors
Modified Risk Factor :
- Hypertension (+)
- Smoking (+)
Non-modified Risk Factor :
- Gender : Male
- Age : > 45 years old

Physical Examination

General State :
- Moderate Illness/underweight/ Concious
- Body Weight : 53 kg
- Body Height : 170 cm
- Body Mass Index (BMI) : 18,33 kg/m2

Vital State :
- Blood Pressure : 120/80 mmHg
- Heart Rate : 52x/min
- Respiratory Rate : 20x/min
- Body Temperature : 37,5 C

Physical Examination
Head and Neck Examinations:
Eye

: Conjunctiva anemic (-/-), sclera icteric (-/-)

Lip

: Cyanosis (-)

Neck

: JVP : R+2 cmH2O

Thoracis Examination
Inspection

: Symmetric left and right

Palpation
left=right

: No mass, no tenderness, vocal fremitus

Percussion

: Sonor

Auscultation

: Breath sound

: Vesicular

Additional sound : Ronchi -/- basal ,

Wheezing -/- .

Physical Examination
Cardiac Examination
- Inspection
: Apex wasnt visible
- Palpation : Apex wasnt palpable
- Percussion : Dull
Upper Right Border : ICS II Linea Para Sternalis Dextra
Lower Right Border : ICS IV Linea Para Sternalis
Dextra
Upper Left Border : ICS II Linea Para Sternalis Sinistra
Lower Left Border : ICS IV Linea Medio Clavicularis
Sinistra
- Auscultation : Heart sound S I/II regular;
sound : Murmur (-)

Additional

Physical Examination
Abdominal Examination
Inspection
: Flat, following breath movement
Auscultation
: Peristaltic sound (+), normal
Palpation
: No mass, no tenderness, no
palpable liver and spleen
Percussion
: Tympani (+), ascites (-)

Extremities Examination
Pretibial edema -/ Dorsum pedis edema -/-

ECG (22/12/2013)

Interpretation
Rhythm
: Sinus Rhythm
Heart Rate
: 56 x/ minute
Axis
: Normoaxis
P Wave
: 0.08 s
PR Interval
: 0.16 s
QRS Duration
: 0.08 s
ST Segment
: ST Elevation in lead II, III, aVF
T inverted
:-

Conclusion
Sinus bradycardia
Normoaxis
Acute inferior wall myocardial infarction

Chest X Ray (24/3/2013)

Result
TB Paru aktif
Dilatatio, elongatio
et atherosclerosis
aortae

Laboratorium Findings
(24/3/2013)
Complete Blood Count
Test

Result

Normal
value

WBC
RBC
HGB
HCT
PLT

10,80 x 103/uL
4,54x 106/uL
13 g/dL
38,5 %
125x 103 /uL

4.0 10.0 x 103

4.0 6.0 x 106
12 16
37 48
150 400 x 103

Blood Chemistry
Test

Result

Normal value

GDS

125 mg/dL

<140

SGOT

54 u/L

<38

SGPT

26 u/L

<41

Test

Result

Normal value

CK-MB

70 u/L

<25

Troponin-T

0,2

<0,05

Cardiac Enzymes

Electrolyte
Test

Result

Sodium
Potassium
Chloride

141 mmol/l
4,1 mmol/l
110 mmol/l

Normal
value
136-145
3.5-5.1
97-111

Diagnosis
STEMI Inferior Onset 12 Hours
Killip I

Therapy

O2 4 lpm via nasal canul

IVFD Nacl 0,9 % 10 drips/min/infusion pump
Anti-plateletAspilet 80 mg 0-1-0
Clopidogrel 75 mg 1-0-0
Anti-coagulantArixtra 2,5 mg/24 hour/ SC
Anti-inflammationSimvastatin 25 mg/ 24
hour/ IV
Anti-anxietyAlprazolam 0,5 mg 0-0-1
Laxadyn syr 0-0-2 cth
Anti-anginaCedocard 5 mg/min/ SP

Discussion...
ACUTE CORONARY
SYNDROME (STELEVATION
MYOCARDIAL
INFARCTION)

Acute coronary syndrome

Myocardial infarction (MI) is rapid
development of myocardial necrosis caused
by imbalance between oxygen supply and
demand of the myocardium.
It results from plaque rupture with thrombus
formation in a coronary vessels, resulting in
an acute reduction of blood supply to a part
of the myocardium.

Classification
Unstable Angina

PATHOPHYSIOLOGY
STEMI generally 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 and when condition
favor thrombogenesis.

Risk Factors
Modifiable:

Hypertension
Diabetes Mellitus
Dyslipidemia
Smoking
Obesity

Gender: male
Age >45 years old
Personal history of
Coronary Artery
Disease
Family history of
Coronary Artery
Disease

Non-Modifiable:

Clinical Features
Duration of chest pain > 20 minutes, at
Substernal
Duration of chest pain > 20 minutes, at
Substernal
Not fully relieved by rest or nitroglyce

Diagnosis
Chest
pain
Acute
coronary
symdrome

Non ST
elevatio
n

ST
elevatio
n

Biomark
er

(+)

STEMI

Non STEMI

(-)

Unstable
angina

Management
Fixing the chest pain and

Based on KILLIP classification

Classification
KILLIP I

Description
No crackles, no 3rd heart sound

KILLIP II

Crackles in <50 % of the lung

field, or a 3rd heart sound

KILLIP III

Crackles >50 % of lung field, lung

udema

KILLIP IV

Cardiogenic shock

TIMI Prognosis in MI
Risk Factor

Score

Age > 65 years old

>/= 75

2
3

History of
1
angina/hipertension/DM
Systolic BP <100

Heart rate >100

Killip II-IV

Weight >67 kg

Anterior MI or LBBB

Delay treatment >4

hours

Total
Scor
e

Risk of
Death in
30 days

0
1
2
3
4
5
6
7
8
9-14

0.8%
1.6%
2.2%
4.4%
7.3%
12.4%
16.1%
23.4%
26.8%
35.9%

Complications
1.
2.
3.
4.

Congestive heart failure

Thromboemboli
Arrhythmia
Cardiogenic shock

THANK
YOU