APRIL 2016

CASE REPORT:
ST SEGMENT ELEVATION
INFERIOR MYOCARDIAL INFARCTION
ONSET > 24 HOURS KILLIP II

Presented by:
Nurhafidah Mahfudz C111 12 058
Andi Saputri Majid C111 12 057
Andi Idil Saputra C111 12 059
Hartati Hamzi C111 12 062

Supervisor:
dr. Abdul Hakim, Sp.JP, FIHA
PATIENT IDENTITY

 Name : Mr. B
 Age : 61 years old
 Address : Mattoanging
 MR : 532990
 Date of Admission : 19/4/2016
HISTORY TAKING

 Chief complaint : Chest pain

 Present Illness History :
 Suffered since 1 day before admission

 Described as burned and compressed pain on the left side

and radiating to left arm and neck, intermittently, duration
of pain : 20-30 minutes, accompanied with cold sweat.
 The intensity is not influeced by activity or rest

 Shortness of breath (+)

 DOE (+)

 PND (+)

 Nausea (+), no vomitting

HISTORY TAKING

 Past Illness History :

 No history of hypertension
 No history of Diabetes Mellitus
 No history of alcohol consumption
 History of smoking (+)
 No history of previous chest pain and heart disease
 No family history with heart disease
 History of lung TB on 2015
RISK FACTOR

Modified Risk Factor

• Smoking

Non-modified risk factor:

• Gender : Male
• Age : 61 years
PHYSICAL EXAMINATION
 General Status
 Moderate illness / Under Nutrition/ Composmentis
 Weight : 45 kg
 Height : 161 cm
 BMI : 17.37 kg/m2
 Vital Status
 Blood pressure :120/70 mmHg
 Heart rate : 100 bpm
 Respiratory rate : 28 rpm
 Temperature : 36,5 oC
PHYSICAL EXAMINATION

 Head : anemic (-) icteric (-)

 Neck : JVP R+2 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

Rhythm : sinus rhytm QRS complex : Q wave in II, III, aVF

Heart Rate : 91 bpm Duration of QRS : 0.06 sec
Regularity : reguler ST segment : elevation in II, III, aVF
P wave : 0.06 sec T wave : T inverted in II, III, aVF
PR interval : 0.16 sec
Axis : extreme right axis deviation Conclusion: STEMI inferior
 LABORATORY FINDINGS

TEST RESULT Normal value

RBC 4,67x106/l 4,50-6,50x106/l

WBC 19,4 x103 /l 4,0-10,0 x 103 /l

HGB 13,91 g/dl 14,0-18,0 g/dl

HCT 43,2% 40,0-54,0 %

PLT 236x 103 /l 150-400 x 103 /l

 LABORATORY FINDINGS

Test Result Normal value

GDS 115 mg/dl 140 mg/dl

Ureum 41 mg/dl 10-50 mg/dl

Creatinin 1,25 mg/dl M(<1,3);F(<1,1) mg/dl

SGOT 13 U/l <38 U/l

SGPT 9 U/l <41 U/l

Natrium 135 mmol/l 136-145 mmol/l

Kalium 4,2 mmol/l 3,5-5,1 mmol/l

Klorida 103 mmol/l 97-111 mmol/l

 LABORATORY FINDINGS

Test Result Normal value

CK 31 U/l L(<190)P(<167) U/l

CK-MB 13 U/l <25 U/l

Troponin I 0,05 ng/ml <0,01 ng/ml

PT 10,9 detik 10-14 detik

aPTT 33,6 detik 22-30 detik

INR 1,05 detik --

CHEST X-RAY

Conclusion:
- CTI 0,31 (normal)
- Active pulmonary TB
- Lymphadenopathy hilar dextra
 ECHOCARDIOGRAPHY

• Normal left and right ventricular systolic

function
• Concentric left ventricular hypertrophy
• Diastolic dysfunction grade I
DIAGNOSIS

1. ST Elevation Extensive Inferior Myocardial

Infarction (STEMI) onset >24 hours, KILLIP II

2. CAP, DD/ Syndrom Obstruction Post TB

3. Diastolic Dysfunction
TREATMENT

 O2 2-4 L/min via nasal cannula

 IVFD NaCl 0,9% 500 cc/24 hours
 Aspilet 160 mg (loading dose), maintenance 1x80 mg tab
 Clopidogrel 300 mg(loading dose), maintenance 1x75 mg
tab
 Captopril 12,5 mg/12jam/oral
 Bisoprolol 1.25mg/24jam/oral
 Nitroglycerin 1mg/jam/ SP
 Atorvastatin 40mg/24 hours/oral
 Arixtra 2,5 mg/24 hours/subcutaneous
 Laxadine syr 0-0-2 tsp
 Alprazolam 0,5 mg 0-0-1
DISCUSSION
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).
 ACS Classification
20

Acute Coronary Syndrome

A. Unstable angina pectoris
B. NSTEMI
C. STEMI
Introduction

• Myocardial ischemia is caused by imbalance

between myocardial oxygen supply and
myocardial oxygen consumption.
• Myocardial infarction (MI) is the rapid
development of myocardial necrosis.

European Heart Journal. Guidelines on the management of stable angina pectoris

Regions of the Myocardium

Lateral
I, AVL,V5-V6

Inferior
II, III, aVF Anterior / Septal
V1-V4
Pathophysiology
RISK FACTORS

Modifiable Non-
Modifiable
CLINICAL PATHWAY
WHO DIAGNOSTIC CRITERIA

• Prolonged chest pain

Ischemic Usually retrosternal location
symptoms • Dyspnea
• Diaphoresis

Diagnostic • Inverted T wave

• ST segment depression or elevation
ECG changes • Pathological Q wave

Serum cardiac • Troponin-T atau I

• CK-MB
marker • CK
elevations • Myoglobin
ISCHEMIC SYMPTOMS
 ECG CHANGES

Hyperacute Phase Complete Evolution Old Infarct

• Non specific ST- • Specific ST-Elevation • Q-Pathologic
Elevation • T inverted • ST segment isoelectric
• T taller and wider • Q-Pathologic • T normal or inverted
CARDIAC BIOMARKERS
GOAL OF TREATMENT

Relieve pain Hemodynamic

stabilization

Myocardial Prevent the

reperfusion complication
 Reperfusion Therapy for Patients with STEMI

*Patients with cardiogenic shock or severe heart failure initially seen at a non–PCI-capable hospital should be transferred for cardiac
catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). †Angiography and
revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
- Reperfusion Therapy -
Thrombolitik
ALTEPLASE

Alteplase 15 mg bolus iv.

50mg iv in 30minutes

35mg iv in 60minutes
 TREATMENT
Bisoprolol Clinical Study shows:
-Limit area of MI
Relieve symptom -re-infarction risk decrease
NTG -prolong life span
Vasodilatation

-Plaque stabilization
-LDL decrease
target: <70mg/dl Atorvastatin -Anti-remodelling
-decrease mortality

Captopril
TREATMENT

 O2 2-4 L/min via nasal cannula

 IVFD NaCl 0,9% 500 cc/24 hours
 Aspilet 160 mg (loading dose), maintenance 1x80 mg tab
 Clopidogrel 300 mg(loading dose), maintenance 1x75 mg
tab
 Captopril 12,5 mg/12jam/oral
 Bisoprolol 1.25mg/24jam/oral
 Nitroglycerin 1mg/jam/SP
 Atorvastatin 40mg/24 hours/oral
 Arixtra 2,5 mg/24 hours/subcutaneous
 Laxadine syr 0-0-2 tsp
 Alprazolam 0,5 mg 0-0-1
ACC/AHA 2007 recommendation:
Loading: Aspirin 300mg Decrease mortality
Clopidogrel 300mg Decrease re-infarction rate

CURE study reported:

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

decrease 20% mortality risk,

infark myocardial non fatal,
stroke
COMPLICATION
PROGNOSIS
KILLIP CLASSIFICATION
CLASS DESCRIPTION MORTALITY RATE (%)

I No clinical signs of heart failure 6

Rales or crackles in the lungs, an S3,

II 17
and elevated jugular venous pressure

III Acute pulmonary edema 30 - 40

Cardiogenic shock or hypotension

IV (systolic BP < 90 mmHg), and evidence 60 – 80
of peripheral vasoconstriction
THANK YOU