APRIL 2017

CASE REPORT:
ST SEGMENT ELEVATION
INFERIOR MYOCARDIAL INFARCTION
ONSET 8 HOURS KILLIP I
Presented by:
Yelly Asta Siusiu I C111 12
893

Supervisor:
dr. Pendrik Tandean, Sp.PD- KKV,
FINASIM
PATIENT IDENTITY

Name : Mr. H
Age : 39 years old
Address : PL Dewakang, Makassar
MR : 797794
Date of Admission : 17/04/2017
HISTORY TAKING
Chief complaint : Chest pain
Present Illness History :
Left chest pain felt since 8 hour ago before admission
Described as burned and compressed pain on the left side,
intermittently, duration of pain : > 20 minutes, accompanied with
cold sweat.
The intensity is influeced by activity or rest
Shortness of breath (+)
Dyspneu On Effort (+)
No fever , nausea and vomitting
Defecation : normal
Urination : normal
HISTORY TAKING

Past Illness History :

History of hypertension (-), DM (-), Dislipidemia (-)
History of alcohol consumption (-)
History of smoking (+) 10 years, 1 packed of
cigarettes per 2 days
No history of previous chest pain and heart disease
No family history with heart disease
RISK FACTOR

Modified Risk Factor

Smoking

Non-modified risk factor:

Gender : Male
PHYSICAL EXAMINATION
General Status
Moderate illness / Overweight/ Composmentis
Weight: 58 kg
Height : 165 cm
BMI : 20.71 kg/m2
Vital Status
Blood pressure :110/70 mmHg
Heart rate : 60 bpm
Respiratory rate : 24 rpm
Temperature : 36,5 oC
PHYSICAL EXAMINATION

Head : anemic (-) icteric (-)

Neck : JVP R+1 cmH2O,
Lung :
Inspection : symmetry left=right
Palpation : mass (-), no tenderness, normal
vocal fremitus
Percussion : sonor
Auscultation : vesicular, ronchi -/-, wheezing -/-
 PHYSICAL EXAMINATION

Cor :
Inspection : ictus cordis not visible
Palpation : ictus cordis is palpable, thrill (-)
Percussion :
Upper border 2nd ICS sinistra

Right border 4th ICS linea parasternalis dextra

Left border 5th ICS linea midclavicularis sinistra

Auscultation : heart sound I/II regular, murmur (-)

PHYSICAL EXAMINATION

Abdomen :
Inspection : flat, follows breath movement
Auscultation : peristaltic (+), normal
Palpation : liver and spleen not palpable
Percussion : tympani

Extremities :
Edema (-)
ELECTROCARDIOGRAPHY

Tgl 17 April
2017, jam
16.17
(pre trombolitik)

Rhythm : sinus rhytm QRS rate : 0.08 sec

Heart Rate : 57 bpm ST segment : elevation in II, III, aVF
Regularity : reguler T wave : normal
Axis : normoaxis
P wave : 0.08 sec
PR interval : 0.18 sec Conclusion: STEMI
inferior
ELECTROCARDIOGRAPHY

Tgl 17 April
2017, jam
18.21(post
trombolitik)

Rhythm : sinus rhytm QRS rate : 0.08 sec

Heart Rate : 62 bpm ST segment : elevation in II, III, aVF
Regularity : reguler T wave : T inverted II, III, aVF
Axis : normoaxis
P wave : 0.08 sec
PR interval : 0.20 sec Conclusion: STEMI
inferior
 LABORATORY FINDINGS

TEST RESULT Normal value

RBC 5,21 x 106/l 4,50-6,50x106/l

WBC 12,35 x 103 /l 4,0-10,0 x 103 /l

HGB 14,3 g/dl 14,0-18,0 g/dl

HCT 41,7% 40,0-54,0 %

PLT 176 x 103 /l 150-400 x 103 /l

 LABORATORY FINDINGS
Test Result Normal value
GDS 116 mg/dl 140 mg/dl
Ureum 16 mg/dl 10-50 mg/dl
Creatinin 0,80 mg/dl M(<1,3);F(<1,1)
mg/dl

SGOT 122 U/l <38 U/l

SGPT 29 U/l <41 U/l
 LABORATORY FINDINGS

Test Result Normal value

CK 1657.00 U/l L(<190)P(<167) U/l
CK-MB 116,1 U/l <25 U/l
Troponin I 6,99 ng/ml <0,01 ng/ml
PT 10 detik 10-14 detik
aPTT 25,1 detik 22-30 detik
INR 0,89 detik --
 DIAGNOSIS

1. ST Elevation Inferior Myocardial Infarction

(STEMI) onset 8 hours, KILLIP I
 TREATMENT
O2 3 Liter/min via nasal cannula
IVFD NaCl 0,9% 500 cc/24 hours
Actylase : 15 mg bolus iv bolus
50 mg/sringepump in 30 minutes
35 mg/syringepump in 60 minutes
Aspilet 160-320mg loading dose immediately and 80-160 mg
continued indefinitely.
Clopidogrel 300-600mg loading dose and 75mg daily
continued for at least 14 days and up to 12 months.
Atorvastatin 40 mg/24 jam/oral
Alprazolam 0,5mg 1x1
Laxadine syrup 10cc/24 jam/oral
Heparin 800 iu/jam/syringpump
Fasorbid 5 mg sublingual (Jika Nyeri Dada)
 DISCUSSION
ST elevation Myocardial infarction
INTRODUCTION

Acute coronary syndromes (ACS) is a term for situations where

the blood supplied to the heart muscle is suddenly blocked
 Myocardial infarction (MI) rapid
development of myocardial necrosis
Definitio
caused by a critical imbalance between
the oxygen supply and demand of the n
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
 PATOPHYSIOLOGY
Atherosklerosis, trombosis at coronary
arteries

Decrease the blood flow into the

heart

Decrease the supply of oxygen and

nutrition

Ischemia myocard

Necrosis

Imbalance supply and consumption of

the oxygen into the heart

Myocardial infarction
RISK FACTORS

Non-
Modifiable
Modifiable
Smoking Gender & Age
Hypertension Men > 45 years old
Diabetes mellitus Women > 55 years
old
Hypercholesterolemi
a Family history
Obesity Heart disease in
biological brother or
Psychosocial stress father > 55 years old
Lack of physical Heart disease in
activity biological sister or
mother > 65 years old
Unstable
Angina NSTEMI STEMI
Occluding
thrombus
Non sufficient to cause Complete thrombus
occlusive tissue damage & occlusion
thrombus mild
myocardial ST elevations on
Non specific necrosis ECG or new LBBB
ECG
ST depression +/- Elevated cardiac
Normal T wave inversion enzymes
cardiac on
enzymes ECG More severe
symptoms
Elevated cardiac
enzymes
GOAL OF TREATMENT

Hemodyna
Relieve mic
pain stabilizatio
n
Prevent
Myocardial
the
reperfusio
complicati
n
on
- Reperfusion Therapy -
Thrombolitik
ALTEPLASE

Alteplase 15 mg bolus iv.

50mg iv in 30minutes

35mg iv in 60minutes
Initial Treatment
Bed rest
Oxygen (2-4 lpm)
Anti platelet therapy :
Aspirin 160-320mg chewed immediately and 80-160 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%.
Morphine 2-5mg iv (can be administered again in 5-30 minutes later)
Fibrinolytic therapy:
Streptokinase 1.5 million units in 100 mL dextrose 5% or NaCl 0,9% finished in 30 60
minutes
Actilyse : 15 mg bolus iv
0.75mg/kg weight body in 30 minutes
and 0,5 mg/kg weight body in 60 minutes
Anticoagulation therapy:
Low Molecular Weight Heparins (Fluxum) 0.4cc/sc for up to 8 days post-MI.
Unfractionated heparin
Anti Hypertension Drugs
COMPLICATIO
N
PROGNOSIS
KILLIP CLASSIFICATION
MORTALITY RATE
CLASS DESCRIPTION
(%)
No clinical signs of heart
I 6
failure
Rales or crackles in the lungs,
II an S3, and elevated jugular 17
venous pressure
III Acute pulmonary edema 30 - 40
Cardiogenic shock or
hypotension (systolic BP < 90
IV 60 80
mmHg), and evidence of
peripheral vasoconstriction
THANK YOU
 SECONDARY PREVENTIONS FOR
PATIENTS WITH STEMI
Weight management (BMI 18.5 to 24.9 kg per m 2; waist

circumference

less than 40 inches in men, less than 35 inches in women)

Diabetes management (A1C less than 7 percent)

Antiplatelet and anticoagulant therapy

Renin-angiotensin-aldosterone system blocker therapy

Beta blocker therapy

ACC/AHA 2007 recommendation:
Loading: Aspirin 300mg Decrease mortality
Clopidogrel 300mgDecrease re-infarction rate

CURE study reported:

Maintanance:
Aspirin 80mg+Clopidogrel 75mg (for1year)

decrease 20% mortality risk,

infark myocardial non fatal,
stroke
ELECTROCARDIOGRAPHY

Tgl 17 April
2017, jam
16.32
(pre trombolitik)
(posterior)

Rhythm : sinus rhytm QRS rate : 0.08 sec

Heart Rate : 60 bpm ST segment : elevation in II, III, aVF
Regularity : reguler T wave : normal
P wave : 0.08 sec
PR interval : 0.18 sec
Axis : normoaxis Conclusion: STEMI
inferior
ELECTROCARDIOGRAPHY

Tgl 17 April
2017, jam
18.26 (post
trombolitik)
(posterior)

Rhythm : sinus rhytm QRS rate : 0.08 sec

Heart Rate : 58 bpm ST segment : elevation in II, III, aVF
Regularity : reguler T wave :normal
P wave : 0.08 sec
PR interval : 0.20 sec
Axis : normoaxis Conclusion: STEMI
inferior