CASE

PRESENTATION

KEPANITERAAN KLINIK ILMU PENYAKIT JANTUNG

FAKULTAS KEDOKTERAN UNIVERSITAS SEBELAS MARET
RS. DR. MOEWARDI SURAKARTA
2018
PATIENT STATUS
IDENTITY
 Name : Mr. D
 Age : 59 yo
 Sex : Male
 Address : Tegalyoso, Klaten
 No MR : 01440400
 Arrival : November, 24th 2018
 Payment : BPJS
CHIEF COMPLAIN
CHEST PAIN
 PRESENT ILNESS
A 59 years old male who prensented with chest pain was admitted to
our hospital. The onset of symptoms since ± 4.5 hour before admitted to
our hospital. The chest pain was like being crushed by heavy object,
spread to the back. Patient felt chest pain lasted for >20 minutes.
The pain got worse while doing activity and relieved when the patient is
resting. There was nausea and cold sweats. There was not palpitate and
vomit. The chest pain get better with ISDN tablet.
The patient has history of coronary herat disease (unstable angina
pectoris) and takes ISDN 3 x 1 mg, captopril 3x10,5 mg, Minospi 1x80mg,
bisoprolol 1x5mg, nitrokaf 2x1mg, amlodipine 1x5 mg, clopidrogel
1x25mg. The patien hasn’t diabetes, hipertension, stroke. The patient
consume cigarette since teenager
 PHYSICAL EXAM
 General condition : moderate ill
 Consciousness : compos mentis
 BP : 130/80 mmHg
 HR/pulse : 65/65 x/min
 RR : 20 x/min
 Oxygen level : 98 %
 GDS : 92

Eyes: CA-/-, SI -/-
Neck: JVP 5 +2 cmH20
bowel sound (+) normal.
ballotement (-), epigastric pain (-)
Cor:
I : Ictus cordis not seen
P: Ictus cordis not lifted
P: Ictus cordis wider
from normal limit with
border enlargement (+),
caudolateral
A: 1st and 2nd heart
sound normal intensity,
reguler, murmur (-),
gallop (-).

Vesicular (+/+) Ronkhi (-/-)

edema (-/-)
cold extremity (-/-)
edema (-/-)
cold extremity (-
/-)
Laboratory Examination
 Pemeriksaan Hasil Satuan Nilai Rujukan
HEMATOLOGI RUTIN 24/11/2018 05:52 AM
Hemoglobin 16.2 g/dl 13.5 – 17.5
Hematokrit 51 % 33 – 45
Leukosit 9.7 ribu/ul 4.5 – 11.0
Trombosit 527 ribu/ul 150 – 450
Eritrosit 5.33 juta/ul 4.50 – 5.90
INDEX ERITROSIT
MCV 94.9 /um 80.0 – 96.0
MCH 30.4 Pg 28.0 – 33.0
MCHC 32.0 g/dl 33.0 – 36.0
RDW 11.6 % 11.6 – 14.6
MPV 9.0 Fl 7.2 – 11.1
PDW 17 % 25 – 65
HITUNG JENIS
Eosinofil 1.90 % 0.00 – 4.00
Basofil 0.10 % 0.00 – 0.200
Netrofil 71.50 % 55.00 – 80.00
Limfosit 22.20 % 22.00 – 44.00
Monosit 4.30 % 0.00 – 7.00
HEMOSTASIS
PT 13.1
APTT 33.9
INR 1.010
KIMIA KLINIK
Gula Darah Sewaktu 78 mg/dl 60 – 140
SGOT 15 u/l < 35
SGPT 26 u/l < 45
Albumin 4.3 g/dl 3.5 – 5.2
Creatinin 1.0 mg/dl 0.9 – 1.3
Ureum 30 mg/dl <50
ELEKTROLIT
Natrium darah 137 mmol/L 136 – 145
Kalium darah 4.1 mmol/L 3.3 – 5.1
Calsium Ion 1.20 mmol/L 1.17 – 1.29
SEROLOGI
HBsAg Non reactive Non reactive
CARDIAC MARKER
CKMB Mass <1.0 ng/mL <4.3
Troponin – I <0.01 ng/mL <0.2
BNP 6 pg/mL <100
ECG Examination
Sinus rythm, HR 75 bpm, normoaxis , p wave (+) in lead II with
normal morphology , PR interval 0.12 sec, QRS complex 0.12
sec. pathological Q wave (+) in V1-V5. Elevated ST segment (+)
in V1-V5, depressed ST segment (-), inverted T wave (+) in lead
I, aVL, and V2-V5.
Chest X-ray Examination
X-Ray PA (8/10/2018)
1. Cor is not valid
2. Pulmo: normal
bronchovascular
features, no infiltrate
3. Good diaphragm
4. Good bone system

Conclusion
(08/10/2018) :
1. Cor is not valid
2. Pulmo shows no
abnormality
DIAGNOSIS
Ax : Unstable Angina Pectoris dd NSTEMI

Fx : Killip 1

Ex : PJK

History : age >45 tahun, male, smoker

PLAN
Therapy : Plan :
• Total bed rest
• Chest x-ray  icvcu
• IVFD RL 60 ml/jam
• O2 3 lpm NK (SpO2 < 90%) • Echocardiography
• DJ II 1700 kkal • Lab
• Aspilet 80 mg/24h
• Clopidogrel 25mg/24h
• Bisoprolol 2,5 mg/24h
• ISDN 5mg/8h
• Ramipril 5mg/24h
• Atorvastatin 40mg/24h
DPH 1
S : breathless (-), chest pain (-), palpitate (-)
O:
 Consciousness : compos mentis
 BP : 120/78 mmHg
 HR/pulse : 66/66 x/min
 RR : 20 x/min
 Oxygen level : 98%

Eyes: CA-/-, SI -/-
Neck: JVP 5 +2 cmH20
bowel sound (+) normal.
ballotement (-), epigastric
pain (-)
Cor:
I : Ictus cordis not seen
P: Ictus cordis not lifted
P: Ictus cordis wider
from normal limit with
border enlargement (+),
caudolateral
A: 1st and 2nd heart
sound normal intensity,
reguler, murmur (-),
gallop (-).

Vesicular (+/+) Ronkhi (-/-)

edema (-/-)
cold extremity (-/-)
edema (-/-)
cold
extremity (-/-)
Laboratory Examination
CARDIAC MARKER (25/11/2018)
CKMB Mass <1.0 ng/mL <4.3
Troponin – I <0.01 ng/mL <0.2
BNP 6 pg/mL <100
 Assesment
Ax : Unstable Angina Pectoris

Fx : Killip 1

Ex : PJK

History : male, age > 45 tahun, smoker

PLAN
Therapy : Diagnostic Planning :
• Total bed rest • Lab
• IVFD RL 60 ml/jam • Echocardiography
• O2 3 lpm NK (SpO2 < 90%) • Cardiac biomarker (Tropinin and CKMB)
• DJ II 1700 kkal
• Aspilet 80 mg/24h
• Clopidogrel 75mg/24h
• Bisoprolol 5 mg/24h
• Ramipril 5 mg/24h
• Atorvastatin 40mg/24h
• Inj. Foundaparinox 2.5mg/24h
• Laxadyn syr 3 C1
DPH 2
S : breathless (-), chest pain (-), palpitate (-)
O:
 Consciousness : compos mentis
 BP : 118/72 mmHg
 HR/pulse : 58/58 x/min
 RR : 17 x/min
 Oxygen level : 97 %

Eyes: CA-/-, SI -/-
Neck: JVP 5 +2 cmH20
bowel sound (+) normal.
ballotement (-), epigastric
pain (-)
Cor:
I : Ictus cordis not seen
P: Ictus cordis not lifted
P: Ictus cordis wider
from normal limit with
border enlargement (+),
caudolateral
A: 1st and 2nd heart
sound normal intensity,
reguler, murmur (-),
gallop (-).

Vesicular (+/+) Ronkhi (-/-)

edema (-/-)
cold extremity (-/-)
edema (-/-)
cold
extremity (-/-)
Laboratory Examination
 Pemeriksaan Hasil Satuan Nilai Rujukan
KIMIA KLINIK 26/11/2018 05:52 AM
HbA1C 4.9 % 4.8-5.9
GDP 96 mg/dl 70-110
Glukosa 2 jam PP 130 mg/dl 80-140
Asam Urat 4.9 mg/dl 2.4-6.1
Kolesterol total 114 mg/dl 50-200

Kolesterol LDL 64 mg/dl 88-203

Kolesterol HDL 33 mg/dl 28-71
Trigliserida 150 mg/dl <150
 Assesment
Ax : UAP low risk

Fx : Killip 1, EF 43-47%

Ex : PJK

History : male, age > 45 y.o, smoker, cardiac disease history

 PLAN
Therapy : Plan diagnostic :
• Total bed rest • EKG (chest pain)
• IVFD RL 60 ml/jam • Lab GDP, G2PP, HBA1C, lipid profil
• O2 3 lpm NK (SpO2 < 90%)
• DJ II 1700 kkal
• Aspilet 80 mg/12h
• Inj. Fundaparinox 2.5 mg/24h
• Bisoprolol 7,5 mg/24h
• ISDN 5mg/8h (k/p)
• Ramipril 10mg/24h
• Atorvastatin 40mg/24h
• Laxadin syr 3 x C1
• Clopidrogel 75mg/24 jam
• Laxadyn syr 3 x C1
ACS - STEMI
 Pathophysiology
Atherosclerosis
• Epithelial injury
• Migration of
monocytes/
macrophages
• LDL lipids
consumed 
foam cells
• Growth factors 
smooth muscle,
collagen,
proteoglycans
• Atheromatous
plaque forms
Pathophysiology
 Distinguishing features

• SA: • UA: • NSTEMI: • STEMI:

plaque platelet platelet complete
adhesion
formation aggregation occlusion
 Precipitated by stress or • At rest or minimal exertion
exertion
• Lasts >20 minutes
 Lasts <20 minutes • Often accompanied by other s/s
 Relieved by GTN or resting • Poor GTN relief
Mechanism of Coronary Thrombus
Formation
Consequences of Coronary
Thrombosis
 Changes in Infarction
• Early Changes
 Changes in Infarction
• Late Changes
Time Event
5-7 Yellow softening from resorption of
days dead tissue by macrophages

7+ days Ventricular remodeling

7 Fibrosis and scarring complete

weeks
 Acute myocardial infarction
The infarct is diffusely hemorrhagic. There is a rupture track through the center of
this posterior left ventricular transmural infarct. The mechanism of death was
hemopericardium.
 Risk Factors
Modifiable Non-Modifiable
• Smoking • Increasing age
• Obesity • Gender (male)
• Diet • Ethnicity
• Lack of exercise • Family History
• High serum cholesterol • ? Diabetes
• Hypertension
• ? Diabetes
 Differential Diagnosis
Cardiac Respiratory
• MI • Pulmonary embolism
• Angina • Pneumothorax
• Pericarditis • Pneumonia
• Aortic dissection

Chest pain

GI Musculoskeletal
• Oesophageal spasm • Costochondriasis
• GORD • Trauma
• Pancreatitis
 Diagnosis
Presenting symptoms
• The presence of substernal chest pain
• Discomfort provoked by exertion or
emotional stress
• Relieved by rest and/or nitroglycerin

ECG abnormalities

Cardiac serum markers

 Investigations
Bedside Obs, ECG, BM
Blood FBC, UE, LFT, lipids, cardiac enzymes, amylase, CRP
Imaging CXR
Special Echo, angiography

UA NSTEMI STEMI
Normal troponin Raised troponin Raised troponin
* ECG normal * ST depression * ST elevation
* Possible ST * Can be normal * Hyperacute T waves
depression * Possible T wave * New LBBB
inversion * T inversion (hours)
* Q waves (days)

* ST elevation is >1mm in limb leads and >2mm in chest leads

Important ECG findings
 Where is the problem?

Inferior II, III, aVF Right coronary

Lateral I, aVL (+V5-6) Left circumflex (or LAD)
Anterior V1-2 septum, V3-4 apex, V5-6 ant/lat LAD
Posterior ST depression in V1-3 Left circumflex or right
coronary
Cardiac Serum Markers

Division of Cardiology
 Management

A Patent?
B Oxygen (aim for sats 94-98%), auscultate, RR
C IV access (+/-fluids), HR, BP
D GCS, pupils, cap blood glucose
E Expose
 Treatment

General • Pain control

measures • Supplemental oxygen

• β blocker
Anti-ischemic • Nitrates
therapies • +/- calcium antagonist

Antithrombotic • Antiplatelet agents

therapies • Anticoagulants

Adjunctive • Statin
therapies • ACE inhibitor
 STEMI
• TIME IS IMPORTANT
• Percutaneous coronary intervention (Primary PCI)
– ‘Call to balloon time’ of 120 minutes
– Requires clopidogrel 600mg loading dose
• Thrombolysis
– Streptokinase / alteplase / tenecteplase…
– Contraindications
– Clopidogrel 600mg loading dose AND LMWH
• Beta blocker i.e. Atenolol
• ACE inhibitor i.e. Lisinopril
 Longer-term management
• Continuous ECG monitoring as inpatient/ CCU
• Aspirin 75mg OD (lifelong)
• Clopidogrel 75mg (1 year)
• Beta blocker (1 year - lifelong)
• ACE inhibitor
• Statin
• Modification of risk factors
 Complications
Early <72hr Late
• Death • Ventricular wall rupture
• Cardiogenic shock • Valvular regurgitation
• Heart failure • Ventricular aneurysms
• Ventricular arrhythmia • Cardiac tamponade
• Myocardial rupture • Dresslers syndrome
• Thromboembolism • Thromboembolism
Complication Mechanisms
Hipertension
 Definition
• Hypertension is defined as office SBP values ≥140 mmHg
and/or diastolic BP (DBP) values ≥90 mmHg.
Classification
Factors influencing cardiovascular risk in patients
with hypertension
 Characteristics of hypertensionmediated
organ damage

• The hearth in hypertension

• CKD
increase in serum creatinine
progressive reduction in eGFR and increased albuminuria
indicate progressive loss of renal Function
• Retinopati
• TIA dan stroke
treatment