CASE REPORT December 2018

ST SEGMENT ELEVATION
MYOCARDIAL INFARCTION INFERIOR ET
POSTERIOR WALL ONSET 1 HOURS KILLIP I

BY :
NURUL FUADI YUSUF
C014172142

SUPERVISOR:
dr. Pendrik Tandean, SpPD-KKV, FINASIM
PATIENT IDENTITY
 Name : Mr. A
 Age : 52 years old
 Address : BTN Pepabri Blok B12/6
 Religion : Islam
 Ethnic : Bugis
 Occupation : PNS
 Medical Record : 763725
 Date of admission: December, 9th 2018
 HISTORY TAKING
Chief complaint : Chest pain
Present illness story
The patient presents in the emergency room with chest pain since
one hour ago, duration > 20 minutes, the pain is felt on the Left
chest region, like heavy pressure, and then radiate to the left arm
and penetrating backward , this complaint accompanied by
diaphoresis. There wasn’t shortness of breath and vomiting. This
complaint provocate by activity and it didn’t get any better with rest
and sublingual nitrate. Patient stop to control in cardiology policlinic
cardiac centre since 7 month ago. He consumes aspilet and
bisoprolol, but no routine.
HISTORY
TAKING
Past Illness History
 History of coronary heart disease, since 2016 on July
with post PCI one stent DES in proximal LAD (total
occlusion proximal)
 History of hiperuricemia, known since 6 months ago
 No History of hypertension
 No history of diabetes mellitus
 No History of dislipidemia
 HISTORY TAKING
History of family past illness
 No History of diabetes mellitus type II
 No history of heart disease

Habitual history

 History junkfood and fried food consumption

 No history of smoking

 No alcohol consumption
PHYSICAL EXAMINATION
General status
• Moderate illness/compos mentis/1st Obesity
• Weight : 80 kg
• Height : 173 cm
• BMI : 26,7 kg/m2

Vital signs
• Blood pressure : 140/100 mmHg
• Heart rate : 100 bpm, regular, hard pulse
• Respiratory rate : 20 rpm
• Temperature : 36,5 ˚C
• O2 Saturation : 98%
PHYSICAL EXAMINATION
Head and neck
Eyes : anemic (-) icteric (-)
Neck : JVP R+2 cmH2O , limphadenopathy (-)

Thorax
1. Lung
Inspection : symmetry left and right
Palpation : mass (-),no tenderness, normal vocal
fremitus
Percussion : sonor
Auscultation : vesicular, ronchi -/-, wheezing-/-
PHYSICAL
2. Cor
EXAMINATION
 Inspection : ictus cordis not visible
 Palpation : ictus cordis is not palpable
,thrill (-)
 Percussion :
-Right upper border at ICS II linea parasternalis
dextra
-Left upper border at ICS II linea parasternalis
sinistra
-Right lower border at ICS IV linea parasternalis
dextra
-Left lower border at ICS V linea axillaris anterior
sinistra
 Auscultation : heart sound I/II regular, no
murmur
Abdomen
Inspection : flat, follows breath movement
Palpation : liver and spleen is not
palpable
Percussion : tympani
Auscultation : peristaltic normal

Extremities
Edema (-), clubbing finger (-), warm
extremity
Laboratory Finding 18/12/10

TEST RESULT NORMAL VALUE

WBC 9.50 [10^3/mm3] 4.0 - 10.0
RBC 5.17 [10^6/mm3] 4.50 - 6.50
HGB 15.8 g/dl 12.0 – 16.0
HCT 40.5 % 37.0 – 48.0
PLT 299 [10^3/mm3] 150 - 400
PT 10.2 s 10 - 14
INR 0.95 -
APTT 24.7 s 22.0 – 30.0
Laboratory Finding 18/12/10

TEST RESULT NORMAL VALUE

Ureum 19 mg/dl 10 – 50
Creatinine 1.08 mg/dl < 1.3
SGOT 52 U/L < 38
SGPT 64 U/L < 41

CK 366 U/L < 190 U/L

CK-MB 35.7 U/L < 25

Troponin I 0.66 ng/l < 0.01
Natrium 140 mmol/l 136 – 145
Kalium 4.1 mmol/l 3.5 – 5.1
Klorida 104 mmol/l 97 – 111
GDS 113 mg/dl 140
Uric Acid 9.3 mg/dl 3.4-7
 Laboratory Finding 18/12/10

TEST RESULT NORMAL VALUE

GDP 98 mg/dl 110
GD2PP 156 mg/dl < 200
HbA1c 5.5 % 4-6
Total cholestrol 186 mg/dl 200
HDL cholestrol 42 mg/dl >55
LDL cholestrol 113 mg/dl <130
Triglyceride 121 mg/dl 200
ELECTROCHARDIOGRAM

Sinus rhytme, HR 100 bpm regular, normoaxis, Acute

inferior et posterior wall myocard infarction
ELECTROCHARDIOGRAM

Sinus rhytme, HR 100 bpm regular, normoaxis, Acute

inferior et posterior wall myocard infarction
 ELECTROCHARDIOGRAM
 Rithm : Sinus rythm
 Heart rate : 100 bpm
 Regularity : Regular
 Axis : Normoaxis
 P Wave : Normal 0,08 second
 PR interval : Normal 0,12 second
 QRS complex : Q wave at lead V1-V4
 Segmen ST : ST elevation at lead II, III, AVF, V7-V9,
ST depression at lead I, AVL, V1-V4
 T Wave : Normal, 0,08 s
Conclusion :
Sinus rhytme, HR 100 bpm regular, normoaxis,
Acute inferior et posterior wall myocard infarction
X-RAY THORAX 18/12/09

• Appear suprahilar vascular

dilatation of both lungs
• Cor : dilate, cor waist is concave,
planted apex (LVE), aorta
dilatation dan elongation
• Both sinus and diaphragm in
normal limited
• Bones in normal limited
• Soft tissue around in normal
limited

Conclutions :
• Cardiomegaly with lung edema
signs
• Dilatatio et elongatio aortae
 ASSESMENT
 ST Segment Elevation Myocardial
Infarction Inferior et Posterior Wall
Onset 1 hour KILLIP I
 Symptomatic Gout Arthritis
 TREATMENT
 NaCl 0,9% 500 cc/24 hours/intravena
 Trombolitik : Alteplase15 mg/bolus intravena (Actilyce)
 Trombolitik : Alteplase 50 mg/ syringe pump/ finish in 3o
minutes
 Trombolitik : Alteplase 35 mg/ syringe pump/ finish in 6o
minutes
 Antiplatelet Cox-1 inhibitor : Loading Aspilet 160
mg/oral -> Aspilet 80 mg/24 hours/oral
 Antiplatelet ADP reseptor inhibitor : Loading
Clopidogrel 300 mg/oral -> Clopidogrel 75 mg/24
hours/oral
 Nitrate : Nitrogliserin 10 mcg/minute/syringepump
 Nitrate : Isosorbid Dinitrate 5 mg/sublingual/if chest pain
 TREATMENT
 Anticoagulant: Fondaparinux 2,5 mg/24
hours/oral
 Statin: Atorvastatin 40 mg/24 hours/oral
 Beta blocker : Bisoprolol 1.25 mg/ 24 hours/oral
(concor)
 Anti inflammation and anti uric acid ->
Colchicine 0,5 mg/8 hours/oral
 Analgetic : Paracetamol 500 mg/8 hours/oral
DISCUSSION
 DEFINITION
Acute Coronary Syndrome
(ACS) is a clinical spectrum that
includes unstable angina,
NSTEMI and STEMI

Myocardial infarction caused by

a critical imbalance between
the oxygen supply and
demand of the myocardium,
which is most often caused by
plaque rupture with thrombus
formation in a coronary vessel,
resulting an acute reduction of
blood supply to a portion of the
myocardium.
CLASSIFICATION
 RISK FACTOR

Modifiable Non-Modifable

• Smoking • Age
• Diabetes • Gender
Mellitus • Family History
• Hyperlipidemia
• Hypertension
• Obesity
 PATOPHYSIOLOGY

Imbalance between myocardial

oxygen supply and demand
PATOPHYSIOLOGY
PATOPHYSIOLOGY
CLINICAL MANIFESTATION
Feeling heavy
Chest pain at burdened or
retrosternal choking
Radiating to the Not heal with rest or
left arm, shoulder nitrat
or neck
In elderly or DM,
Crescendo pain without chest pain
Sweating,
Duration more weakness,
than 20 minutes shortness of breath,
fainting

Sudoyo AW, Setiyohadi B, Alwi I, dkk. Buku Ajar Ilmu Penyakit Dalam Jilid II edisi V. Jak
Interna Publishing; 2010.
 DIAGNOSIS
Anamnesis : Chest discomfort,
sweating

ECG : ST elevation > 2 mm elevation,

minimal at 2 precordial leads or > 1 mm
in 2 limb leads

Cardiac enzyme test : increase troponin I

and other cardiac enzyme markers
ELECTROCARDIOGRAM
 ECG CHANGES

Hyperacute Complete Old

phase Evolution Infarction
• Non specific • Specific ST- • Q-Pathologic
ST-Elevation Elevation • ST segment
• T taller and • T inverted isoelectric
wider • Q-Pathologic • T normal or
inverted
 Q WAVES/ ST CORONARY
INFARCTION AREA
ELEVATION ARTERY
SEPTAL V1 and V2 LAD

ANTERIOR V3 and V4 LAD

LATERAL I, aVL, V5 and V6 LCX

POSTERIOR V7-V9 LCX PL

INFERIOR II, III, AVF PDA

ANTEROSEPTAL V1-V4 LAD

ANTEROLATERAL I, aVL, V4-V6 LAD, LCX

EXTENSIVE
I, aVL, V1-V6 LAD, LCX
ANTERIOR
RIGHT VENTRICLE V2R-V4R RCA
Sudoyo AW, Setiyohadi B, Alwi I, dkk. Buku Ajar Ilmu Penyakit Dalam Jilid II edisi V. Jakarta: Interna
Publishing; 2010.
ENHANCEMENT CARDIAC
BIOMARKERS
 TREATMENT
General Management Management at
 Oxygen- Oxygen: oxygen supplement should Hospital
be given there patient with oxygen
• ICCU
saturation <90%.
 Nitroglycerin: Sublingual nitroglycerin can be • 1) Activity: patient should rest
safely administered at a dose of 0.4 mg within the first 12 hours
 Morphine: very effective in reducing chest • 2) Diet: the patient should fast or
pain and is an analgesic of choice in STEMI just drink liquid by mouth in 4-12
management. hours due to the risk of vomiting
 Aspirin: is the basic management of STEMI- • 3) Sedation: the patient requires
suspected patients and is effective in the sedation during treatment to
spectrum of acute coronary syndromes. maintain a period of inactivity
 Beta Blocker: If morphine does not succeed with a sedative
in reducing chest pain, intravenous beta- • 4) Bowels: resting in bed and the
blocking may be effective. The usual effects of using narcotics to
regimen is metoprolol 5 mg every 2-5 relieve pain often leads to
minutes to a total of 3 doses, with the heart
constipation, so it is
rate> 60 times per minute, systolic blood
recommended the use of
pressure> 100 mmHg, PR interval <0.24
seconds and ronki no more than 10 cm from commodity chairs beside the
the diaphragm bed, high fiber diet, and the use
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. 2015. Pedoman Tatalaksana Sindrom Koroner
Akut. Jakarta. Centra Communications.
of mild laxatives regularly such
as dioctyl sodium sulfosuccinate
GOAL OF TREATMENT

Relieve pain and Hemodynamic

fear stabilization

Myocardial Prevent
reperfusion complication
Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. 2015. Pedoman Tatalaksana Sindrom Koroner Akut. Jakarta.
Centra Communications.
Antman EM, Hand M, Armstrong PW, et al. Focused update of the ACC/AHA 2004 guidelines for the management of the
patients with ST- elevation myocardial infarction : a report of the American College of Cardiology American Heart
Association Task Force on Practice Guidelines. 2008;51:210–247.
 COMPLICATION

Sudoyo, A.W., B. Setiyohadi, et al. 2006. Buku Ajar Ilmu Penyakit Dalam. Edisi ke-4, Pusat Penerbitan
Departemen Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia. Jakarta.
 PROGNOSIS
KILLIP CLASSIFICATION

CLAS MORTALITY
DESCRIPTION
S RATE (%)

I No clinical signs of heart failure 6

Rales or crackles in lungs, an S3, and

II 17
elevated jugular venous pressure

III Acute pulmonary edema 30-40

Cardiogenic shock or hypotension
(systolic BP <90 mmHg), and
IV 60-80
evidence of peripheral
vasoconstriction

David, L.C., S. Jamshid, et al. 2015. Acute Coronary Syndrome. Medscape

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