By :

Mohd Farhannuddin B. Saidin

Supervisor :
Dr. Khalid Saleh,SpPD

Patient Identity
Name

: Mrs. P

Age

: 80 years old

Address

: Jl. Patedong Luwu

Medical record : 559250

Admitted

: July 12th , 2012

History Taking
Chief complaint: Shortness of breath
History taking:
Felt since 1 month ago and worsen 10 days before

admitted to the hospital. The symptom occurred

during activity and not influenced by weather.
Patient always sleep using 2-3 pillow and always
woke up at night due to shortness of breath.
Shortness of breath was accompanied by chest
pain. Patient felt weighted on her left chest for 30
minutes, pain penetrates to the back of the body
and shoulder. The pain did not improved by rest.
Sweating (+) , Dyspnea (+), Nausea (+), Vomiting
(+),
Epigastric pain (+), Cough(+),
Defecation & urination is normal

History of illness

Hypertension (+) since 10 years ago, do not

controlled regularly.

Diabetes mellitus (-)

History of dyslipidemia (-)

History of personal cardiovascular disease (-).

Family history of heart disease (+)

Risk factor

Physical Examination
General Status :

Moderate-illness/normal BW/conscious

Vital Sign :
Blood Pressure : 130/90 mmHg
Pulse

: 112 bpm, regular

Respiratory rate
Body temperature

: 28 tpm, abdominothoracal
: 36,7 C

Head Examination
Eyes : anemic -/-, icterus -/ Lip : cyanosis (-)
Neck : lymphadenopathy (-), JVP R +2 cmH2O
Chest Examination
Inspection
: symmetric R=L, normochest
Palpation
: mass (-), tenderness (-), VF
R=L
Percussion
: sonor
Auscultation : breath sound :bronchovesicular
additional sound : ronchi - /+ /+
+/+
wheezing -/-

Cardiac Examination
Inspection : IC wasnt visible
Palpation : IC wasnt palpable
Percussion : normal heart size
-

Upper border:
Lower border:
Right border :
Left border :

left 2nd ICS

left 5th ICS
right parasternalis line
left medioclavicular line

Auscultation : Regular of I/II heart sound, murmur

(-)
-

Abdominal Examination
- Inspection
: flat and following breath
movement
- Auscultation : peristaltic sound (+) ,
normal
- Palpation
: liver and spleen unpalpable
- Percussion
: tympani, ascites (-)

Extremities
- Oedema : pretibial -/-

dorsum pedis -/-

LABORATORY
FINDINGS

Electrolyte (July, 12h 2012)

Sodium : 132 mmol/L

Potassium : 8.3 mmol/L
Chloride : 99 mmol/L

Cardiac Enzyme (July, 12th 2012)

CK
: 164 U/L
CK-MB : 12 U/L
Trop. T : >2.0

ECG

Interpretation
- Sinus thacycardia
- HR 107 x/minute
- Normal Axis
- ST elevation in V1-V4

ECHOCARDIOGRAPHY

Echocardiography
Conclusion
Decrease LV contractility function

,EF 38 %
LA Dilatation
LVH (+)
Global hypokinetic
MR trivial
Diastolic dysfunction
Pleural efusion

WORKING DIAGNOSIS
STEMI Anteroseptal Wall onset >24 hours

Killip III

MANAGEMENT

Bed rest
O2 2-4 L/min
IVFD NC 500cc/24h/iv
Diuretic : Lasix 2amp/12hrs/iv
Nitrate :
Cedocard 1mg/hrs/sp
Anti-platelet aggregation :
Aspilet loading 80 mg (2 tab), maintenance 1-0-0
Clopidogrel loading 75mg (4tab), maintenance 0-1-0
Anti-coagulant : Arixtra 2,5mg/24hrs/SC
Anti- hypertension : Captopril 12,5 mg 1-1-1
Cholesterol: Simvastatin 20mg (0-0-1)
Anti-anxiety : Alprazolam 0.5 mg (0-0-1)
Laxative: Laxadyne syr 0-0-2C

Acute Myocardial
Infarction

DEFINITION
Myocardial infarction (MI) is rapid
development of myocardial necrosis
caused by imbalance oxygen supply and
demand of the myocardium.

It

results from plaque rupture with

thrombus formation in a coronary
vessels, resulting in an acute reduction
of blood supply to a part of the
myocardium.

PATHOPHYSIOLOGY
Occurs when coronary

blood flow decreases

abruptly after a
thrombotic occlusion of
a coronary artery
previously affected by
atherosclerosis.
In most cases,

infarction occurs when

an atherosclerotic
plaque fissures,
ruptures, or ulcerates

RISK FACTORS
Modifiable:

Hypertension
Diabetes Mellitus
Smoking
Hypercholesterolemia
Low HDL cholesterol(<40mg/dl)
Hypertrigliceridemia(> 200mg/dl)
Obesity
Non-modifiable:
Gender: male
Age (Men > 45 years; women> 55 years)
Personal history of Coronary Artery Disease
Family history of premature Coronary Artery
Disease (CAD in male 1st-degree relative < 65
years)

CLINICAL FEATURES
Deep and visceral chest pain > 20

minutes, similar to discomfort of angina

pectoris but commonly occurs at rest,
more severe, and lasts longer.2
Feels like heavy, squeezing,
crushing, burning sensation.2
Involves the central portion of chest
and/or the epigastrium, radiates to the
arm, abdomen, back, lower jaw, and
neck.2
It is often accompanied by weakness,
sweating, nausea, vomiting, anxiety.2
Not relieved by rest or nitrat.1

WHO Diagnostic criteria of

MI
1.
2.
3.

Clinical history of ischaemic type chest

pain lasting >20 minutes
Changes in serial ECG tracings (STsegment elevation or new onset LBBB)
Rise of serum cardiac biomarkers: CKMB,
Troponin T/I

Diagnose
Signs of myocardial ischemia
ECG
ST segmen elevation ?

Yes

Acute Myocardial
Infarction
( Q-wave, non-Q
wave )

No Lab
Biochemical cardiac markers ?

No

Yes

NSTEMI
( No ST-Segment
Elevation
Myocardial
Infarction )
Unstable Angina

Management
Fixing the chest pain and fearness1
oBed rest
oDiet
oO2 2-4 lpm via nasal prongs or face mask
oSublingual/oral/IV nitroglycerine
oAntiplatelet: aspirin and clopidogrel
oMorfin/petidine
oDiazepam 2-5mg/8 hour
Stabilizing the hemodynamic (blood
pressure and peripheral pulse control)1
o-blocker
oCalcium channel blocker (CCB)
oACE-Inhibitor
Reperfusion of the myocard1
oThrombolytic

Surgical revascularization
PTCA (percutaneous transluminal
coronary angioplasty)
CABG (coronary artery bypass
grafting)

RISK COMPLICATION of MI
Based on KILLIP classification:
Classification
KILLIP I
KILLIP II

Description
No crackles, no 3rd heart sound
Crackles in <50% of the lung
field, or a 3rd heart sound

KILLIP III

Crackles in > 50% of lung field,

lung edema

KILLIP IV

Cardiogenic shock

COMPLICATION of MI
1. Congestive heart failure
2. Myocardial rupture
3. Arrhythmia
4. Pericarditis
5. Cardiogenic shock

TIMI Prognosis in MI
Risk Factor
Age > 65 years old
Age > 75 years old
History of
angina/hypertension
/ DM
Systolic BP <100
Heart rate > 100
Killip II-IV
Weight > 67kg
Anterior MI or LBBB
Delay treatment
>4hours

Score
2
3
1
3
2
2
1
1
1

Total
Score
0
1
2
3
4
5
6
7
8
9-14

Risk of Death in
30 days
0.8%
1.6%
2.2%
4.4%
7.3%
12.4%
16.1%
23.4%
26.8%
35.9%

RISK FACTORS

THANK YOU