STEMI

ANTEROSEPTAL
ONSET < 6 HOURS
KILLIP II

By:
Andi Mulawarman
Supervisor
dr. Abdul Hakim Alkatiri, Sp.JP, FIHA

STEMI

Case report

PATIENTS IDENTITY

Name
: Mr. S
Age
: 34 y.o.
MR
: 696854
Admitted : January 14th 2015

HISTORY TAKING

Chief complaint
Chest pain on the left side

Present illness history

Suffered since 3 hours ago
Described as compressed and radiating pain

from left back to part of neck, consistent,

worsening with activity and abate with resting,
cold sweating, duration of pain > 30 minutes
No DOE, PND and orthopnea
No nausea and vomitting

HISTORY TAKING

Past illness history

No history of previous chest pain
History of Hypertension denied
History of Diabetes denied
Family history of heart disease present

biological mother
History of smoking > 20 years consist of 2
packs/day

PHYSICAL EXAMINATION

General status
Moderate illness/well nourished/ conscious

Vital status
BP

: 110/80 mmHg
HR : 78 x/minutes
RR : 28 x/minutes
T : 36.5 oC

PHYSICAL EXAMINATION

Head: anemic (-) icteric (-)

Neck : JVP R+2 cmH2O,
Lung :
Inspection

: symmetry left=right
Palpation : mass (-), no tenderness
Percussion : sonor left=right
Auscultation
: vesicular, ronchi on lung
base bilateral, wheezing -/-

PHYSICAL EXAMINATION

Cor :
Inspection

: ictus cordis not visible

Palpation

: ictus cordis not palpable, thrill (-)

Percussion :
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea axillaris anterior sinistra

Auscultation: heart sound I/II pure, regular,

murmur (-)

PHYSICAL EXAMINATION

Abdomen :
Inspection

: flat, follows breath movement

Auscultation: peristaltic (+), normal

Palpation

: liver and spleen not palpable

Percussion : tympani

Extremities
Edema (-)

LABORATORY FINDINGS
Laboratorium tests

Results

WBC

15.9 x 103 /mm3

HGB

15.4 g/dl

PLT

309 x 103 /mm3

CK

107 U/L

CK-MB

17.9 U/L

Troponin T

< 0.1 U/L

GOT/GPT

29/45 U/L

GDS

178 mg/dl

Uric acid

5.8 mg/dl

Ureum

22 mg/dl

Creatinin

08 mg/dl

Na/K/Cl

142/4.4/111 mmol/l

ELECTROCARDIOGRAPHY
Sinus rhytm
HR
: 125 bpm
Axis
: normoaxis
PR-Interval : Normal
P-Wave
: Normal
QRS Duration
: 0,12
minute
ST-segment :
ST elevation on V1-V4
T-wave
: Normal

Conclusion
Sinus rhytm normoaksis,
ST elevation on V1-V4,
(Anteroseptal infarction)

CHEST X-RAY

Result :
Cardiomegaly
(CTI index :
0.61) with
dilatation aorta

DIAGNOSIS

ST Elevation Myocardial Infarction

(STEMI) Anterior, onset < 6 hours, Killip
II

TREATMENT

O2 4 lpm via nasal kanul

IVFD NaCl 0,9% 500 cc/24 hrs
Streptokinase 1.5 million unit in NaCl 0.9% 100 cc over 1 hr
Furosemide 40 mg/12 hrs/iv
Aspilet loading dose 160 mg, maintenance 80mg/24 hrs/oral
Clopidogrel loading dose 300 mg, maintenance 75mg/24
hrs/oral
Farsorbid 5 mg/8 hrs/sublingual
Simvastatin 20 mg/24 hrs/oral
Laxadine 10 cc/24 hrs/oral
Alprazolam 0.5 mg/24 hrs/oral

STEMI

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).

INTRODUCTION

UAP

Non occlusive
thrombus
Non specific
ECG
Normal cardiac
enzymes

NSTEMI
Occluding
thrombus
sufficient to cause
tissue damage &
mild
myocardial
necrosis
ST depression +/T wave inversion
on
ECG
Elevated cardiac
enzymes

STEMI
Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms

Pathophysiology

RISK FACTORS
Modifiable
Smoking
Hypertension
Diabetes mellitus
Hypercholesterolemia
Obesity
Psychosocial stress
Lack of physical activity

NonModifiable
Gender & Age
Men > 45 years old
Women > 55 years
old
Family history
Heart disease in biological
brother or father > 55 years
old
Heart disease in biological
sister or mother > 65 years
old

WHO DIAGNOSTIC CRITERIA

Ischemic
symptoms

Prolonged chest pain

Usually retrosternal location
Dyspnea
Diaphoresis

Troponin-T
CK-MB
CK
Myoglobin

Diagnostic
ECG
changes
Serum
cardiac
marker
elevations

INFARCT LOCATION

CARDIAC BIOMARKERS
MARKER

NORMAL VALUE

CK

L (<190), P (<167)

CK-MB

<25

TROPONIN-T

<0.05

CARDIAC BIOMARKERS

GOAL OF TREATMENT
Relieve pain

Hemodynam
ic
stabilization

Myocardial
reperfusion

Prevent the
complication

INITIAL TREATMENT

Bed rest
Oxygen (2-4 lpm)
Anti platelet therapy :
Aspirin 162-325mg chewed immediately and 81-162 mg

continued indefinitely.
Clopidogrel 300-600mg loading dose and 75mg daily

continued for at least 14 days and up to 12 months.

Nitroglycerin :
0.4 mg SL tablets every 3-5 min up to 3 times; if effect is

not sustained, can continue with an IV drip of 50mg in

250mL Dextrose 5%.

INITIAL TREATMENT

Morphine 2-5mg iv (can be administered again in

5-30 minutes later)

Fibrinolytic therapy:
Streptokinase 1.5million units iv
Tenecteplase 0.5mg/kg body weight iv

Anticoagulation therapy:
Low Molecular Weight Heparins (Fondaparinux)

2.5mg/24hrs/sc for up to 8 days post-MI.

Unfractionated heparin

Anti Hypertension Drugs

Lipid Lowering Agents

COMPLICATIONS
Ventricular
dysfunction

Hemodynam
ic
disturbance
s

Cardiogenic
shock

Arrhythmia

PROGNOSIS
CLASS

DESCRIPTION

MORTALITY RATE
(%)

No clinical signs of heart

failure

II

Rales or crackles in the lungs,

an S3, and elevated jugular
venous pressure

III

Acute pulmonary edema

30 - 40

IV

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

60 80

17

THANK YOU

CHEST PAIN

CARDIAC BIOMARKERS

NON-ACS TROPONIN ELEVATION

ANTITHROMBOTICS