Case Report

Medical Faculty of Hasanuddin University, Makassar 2013

 Patient Identity

• MR number : 151821
• Name : Mr.SU
• Age : 65 years old
• Date administered : May 4th 2013
 History Taking
Chief complaint: Chest pain
• It was felt since 9 hours before admitted to hospital. It was felt at
the middle of chest, like pressed by a heavy things and radiated
to his neck and left arm. It occured suddenly with duration more
than 20 minutes, didn’t trigerred by activity and didn’t relieved by
rest.
• Shortness of breath (+), since 1 months ago, he can sleep with 1-
2 pillow. DOE (+) , PND (-), Orthopnea (-)
• Cough (-)
• Epigastric pain (+), Nausea (+), vomit (-), sweating (+)
• Defecation: normal
• Micturition: normal
 Past Medical History
• History of hypertension (+) since long time ago and took medicine regularly

• History of diabetes mellitus (+) since 10 years ago took medicine regularly

• History of dyslipidemia (-)

• History of smoking (-)

• History of hospitalization with stroke in 2000, 2006, and 2011

• History of chest pain before (-)

• Family history (-)

 Risk Factor
Modifiable : Non - Modifiable :
- Hypertension - Gender (male)
- Diabetes mellitus - Age : 65 years old
- Stroke
 Physical Examination
• General status
Moderate illness/well nourished/conscious
• Vital sign
– BP : 130/90 mmHg
– HR : 80 x/min
– RR : 28x/min
–T : 36.70 C
 Physical Examination
Regional status
Head Examination
- Eyes : Anemis -/-, icterus -/-
- Lip : Cyanosis (-)
- Neck : JVP R +3 cmH2O

Chest Examination
- Inspection : Symmetric right = left, normochest
- Palpation : No mass, no tenderness
- Percussion : Sonor, lung-liver border in ICS VI right anterior
- Auscultation : Breath sound : Bronchovesicular
Additional sound : Ronchi +/+ basal, wheezing -/-
Cardiac Examination
- Inspection : Ictus cordis invisible
- Palpation : Ictus cordis impalpable
- Percussion : Right heart border in right parasternal line, left heart border
midclavicle line ICS V
- Auscultation : Regular of I/II heart sound, no murmur

Abdominal
- Inspection : flat, following breath movement
- Auscultation : Peristaltic sound (+), normal
- Palpation : No mass, no tenderness, liver and spleen unpalpable
- Percussion : tymphani, ascites (-)

Extremities
- Oedema pretibial -/-
- Oedema dorsum pedis -/-
Electrocardiography (ECG)
Interpretation:
Rhythm : Sinus rhytm
HR/QRS rate: 83 x/min
Axis : Normal
P wave: 0.08 sec
PR interval: 0.2 sec
QRS Complex: 0.16 sec
ST segmen: ST elevasi V1-V4
T wave : T inverted pada lead II, III, AVF
 Laboratory Findings
RESULT NORMAL
WBC 8.440 [10^3/uL] 4.0-10.0
RBC 4.05 [10^6/uL] 4.00-5.00
HGB 12.9 [g/dL] 12.0-16.0
HCT 37.8[%] 37.0-48.0
PLT 271[10^3/uL] 150-400
CK 760 [U/L] L(<190), P(<167)
CK-MB 52 [U/L] <25
TROPONIN-T 0.27 negative

CHOL TOT 288 150-200

 LABORATORY FINDINGS
RESULT NORMAL

GDS 269 140

HbA1C 5.9 4-6

UREUM 45 10-50

CREATININE 1.4 L(<1.3), P(<1,1)

SGOT 47 <38

SGPT 32 <41

NATRIUM 143 136-145

KALIUM 3.8 3.5-5.1

CHLORIDE 1109 97-111

Thorax Photo
Interpretation:
In Normal Limit
Echocardiography
 Echocardiography
• Interpretation

• Sistolic and diastolic LV disfunction, EF 38%

• LVH (+)

• Anterior, apical, apico septal, and mid septal hipokinetic

• EV function good (TAPSE 1,9)

• MR Mild-Mud
 Working Diagnosis

STEMI Anterior Wall Onset 9 Hrs KILLIP II

Hypertention Gr I
DM type II
 Initial Management
• Bed rest
• Cardiac Diet
• O2 3-4 ltr/min
• IVFD NaCl 0,9 % 10 drips/min
• Isosorbid dinitrat : Cedocard 2mg/amp/jam
• Simvastatin 20 mg 0 – 0 – 1
• Anti platelet aggregation :
- Aspirin : Aspilet 80 mg loading dose 2 tab  80 mg 0 – 1 – 0
- Clopidogrel: Plavix 75 mg loading dose 4 tab  75 mg 1 – 0 – 0
• Anticoagulant : Arixtra 2,5 mg/24 h/ SC
• ARB : Valsartan 80 mg 0-0-1
• Anti anxietas : Alprazolam 0,5 mg 0 - 0 - 1
• Stool softener : Laxadyn syrup 0 - 0 - 2C
• Novorapid 6-6-6
• Lantus 0-0-12
 DISCUSSION :

Acute Coronary Syndrome

(ST-Elevation Myocard Infarction)
• 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 A NGINA PECTORIS

Regions of the Myocardium

Lateral
I, AVL,V5-V6

Inferior
II, III, aVF Anterior / Septal
V1-V4
EUROPEAN HEART JOURNAL. GUIDELINES ON THE MANAGEMENT OF STABLE A NGINA PECTORIS
Diagnosis
 WHO Diagnostic Criteria

• Clinical history of ischaemic type chest pain

lasting >20 minutes
• Changes in serial ECG tracings
• Rise and fall of serum cardiac biomarkers such
as creatinine kinase-MB fraction and troponin

HTTP://EN.W IKIPEDIA.ORG/WIKI/MYOCARDIAL_INFARCTION
CARDIAC BIOMAKERS
RISK FACTORS FOR ATHEROTHROMBOSIS
Hypercoagulable states Life-style (e.g, smoking,
Hyperlipidemia
diet, lack of exercise)

Homocysteinemia Hypertension

Diabetes Gender

Obesity Infection?

Genetics Age
Atherotrombotic Manifestations
(MI, Ischemic stroke, Vascular death)

American Heart Association, Heart and Stroke facts: 1997 Statistical supplement;
Wolf Stroke 1990;21 (SUPPL 2):II-4II-6;Laurila et al. arterioscle TrombVasc bio 1997;17:2910-2913;Grau et
al. Stroke 1997;26;1724-1729; Graham et al JAMA 1997;277: 1775-1781;Brigden Postgrad Med;101(5);249-
262
 Treatment
• Relieve pain
• Hemodinamic stabilitation
• Miokardial reperfusion
• Prevent the complication

KABO P. BAGAIMANA MENGGUNAKAN OBAT-OBAT KARDIOVASKULAR SECARA RASIONAL. 2010

 Treatment
• Oxygen Surgical revascularization
• Nitrate • PTCA (percutaneous
• Anti platelet agent transluminal coronary
• Anti koagulan angioplasty)
• Morphine / pethidine • CABG (coronary artery
• Trombolitic bypass grafting)

• ß-blocker
• ACE inhibitors
• Lipid lowering agent

KABO P. BAGAIMANA MENGGUNAKAN OBAT-OBAT KARDIOVASKULAR SECARA RASIONAL. 2010

 Prognosis
KILLIP CLASSIFICATION
Class Description Mortality Rate (%)
I no clinical signs of heart failure 6
II rales or crackles in the lungs, an S3, 17
and elevated jugular venous pressure
III acute pulmonary edema 30 - 40
IV cardiogenic shock or hypotension 60 – 80
(systolic BP < 90 mmHg), and
evidence of peripheral
vasoconstriction

HTTP://EN.W IKIPEDIA.ORG/WIKI/KILLIP_CLASS
 TIMI score for UAP and NSTEMI
• 1. Age > 65 years
• 2. More than 3 risk factors - hypertension, diabetes mellitus, smoking,
family history, dyslipidaemia
• 3. Prior coronary angiogram showing > 50% stenosis
• 4. Aspirin use in the past 7 days
• 5. At least 2 episodes of rest pain in the past 24 hours
• 6. ST deviation on admission > 1 mm
• 7. Elevated cardiac markers - CK, CKMB, Troponin T

• Low 0-2 : < 8.3% risk of adverse cardiac event

• Intermediate 3-4 : < 19.9 % risk of adverse cardiac event
• High 5-7 : up to 41% risk of adverse cardiac event
HTTP://DOKNOTES.WIKIDOT.COM/TIMI-SCORE-FOR-UNSTABLE-ANGINA-AND-NSTEMI
Thank You