Anteroceptal

ST Elevation Myocardial Infarction

Nurul Fitrawati R (C11109132)

Supervisor : Prof. dr. Peter Kabo, PhD,
SpFK, SpJP(K), FIHA, FAsCC

CARDIOLOGY DEPARTMENT
MEDICAL FACULTY OF HASANUDDIN UNIVERSITY
MAKASSAR 2014

Patient Identity
Name
: Mr. M
Age
: 55 years old
Gender
: Male
Address
: Jl. Rusa BTN Blok F No. 8,
Makassar
Medical Record: 661765
Date of Admission: May 2nd, 2014

History Taking
CHIEF COMPLAIN Chest Pain
PRESENT ILLNESS HISTORY
Chest pain was felt since 20 hours before admitted to
the hospital. Pain was felt on the left side of chest and
radiated to the shoulder, and his left arm. Pain was felt
on the left suddenly for more than 20 minutes. Chest
pains not influenced by activity and does not
disappear with rest. Cold sweat (+), palpitations (+),
shortness of breath (-).

Fever (-), history of fever (-)

Dizziness (-), headache (-)
Cough (-), mucus (-)
Nausea (-), vomiting (-), epygastric pain (-)
Normal urination and defecation

Continue..

Previous Illness History

History of diabetes mellitus (-)
History of hypertension (-)
History of dyslipidemia (-)
History of smoking (+) since 10 years ago.
History of chest pain before (-)

History of heart diseases (-)

Family history with heart disease (-)

Risk Factors
Modifiable
Modifiable Risk
Risk
Factor
Factor

Diabetes
Mellitus

Non-modifiable
Non-modifiable
Risk
Risk Factor
Factor

Female
> 60
years old

Physical Examination
GENERAL
APPEARANCE
- Moderate Illness/Well Nourished/ Composmentis
- Body Weight : 60 kg
- Body Height : 160 cm
- Body Mass Index (BMI) : 22.2 kg/m2

VITAL SIGN

BP : 100/70 mmHg
HR : 76 x/min
RR: 20x/min
T
: 36.80 C

REGIONAL STATE
Head Examination

- Eyes : Anemis -/-, icterus -/- Lip : Cyanosis (-)

- Neck: JVP R +2 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 : Vesicular
Additional sound : Ronchi -/Wheezing -/-

 Cardiac Examination
- Inspection
: Ictus cordis invisible
- Palpation
: Ictus cordis impalpable
- Percussion
: Right heart border in right parasternal
line, left heart border in left midclavicle
line ICS V
- Auscultation : Regular of I/II heart sound, no murmur

Abdominal
- Inspection
- Auscultation
- Palpation
unpalpable
- Percussion

Extremities

: flat, following breath movement

: Peristaltic sound (+), normal
: No mass, no tenderness, liver and spleen
: tymphani, ascites (-)

- Oedema pretibial -/- Oedema dorsum pedis +/+

Continue

Chest X-Ray (2/5/2014)

Suprahyllar
bronchovascular
dilatation patterns
within broad hyllar
Normal CTI, aorta
dilatation
No abnormalities on
both sinuses and
diaphragm
Intact bones
Result
Signs of pulmonary
stank
Aorta dilatation

ECG (2/5/2014)

ECG Interpretation
Rhythm
: Sinus Rhythm
Heart Rate
: 75x/ minute
Axis
: Normal axis
P Wave
: 0.08 s
PR Interval
: 0.16 s
QRS Duration
: 0.08 s
ST Segment
: ST Elevation on V1-V4
T inverted
:

Result : Sinus Rhythm, Heart Rate 75x/minute, Normal axis,

Anteroceptal miocard infarction

Laboratory Findings (2/5/2014)

Complete Blood Count
Test

Result

Normal value

WBC

14 x 103/uL

4.0 10.0 x 103

RBC

4,11x 106/uL

4.0 6.0 x 106

HGB

12,5 g/dL

12 16

HCT

37,3 %

37 48

PLT

173x 103 /uL

150 400 x 103

Continue

Blood Chemistry
Test

Result

Normal value

RBG

111 mg/dL

<140

SGOT

355 u/L

<38

SGPT

71 u/L

<41

Ureum

18

10-50

Creatinin

0,9

L(<1,3) P(<1,1)

Total Cholesterol

150 mg/dl

200

HDL Cholesterol

34 mg/dl

L (<55) P(<65)

LDL Cholesterol

104 mg/dl

<130

Continue

Cardiac Enzymes
Test

Result

Normal value

Troponin-T

>2

<0,05

CK

4545

L(<190), P(<167)

CK-MB

92

<25

Working Diagnosis
Anteroceptal
ST Elevation Myocardial Infarction
Onset > 12 hours KILLIP I

Therapy

Bed rest
O2 4 lpm via nasal canul
Anti-Platelet: Aspilet 80 mg (loading dose 2x80 mg)
Clopidogrel 75 mg (loading dose 4x75 mg)
Anticoagulant: Lovenox (LMWH) 0,6 cc/12 hours/SC
Nitrat: Cedocard 1 mg/hour/SP
Statin: Simvastatin 1x 20 mg
Anti-anxietas: Alprazolam 0,5 mg 0-0-1
Laxative: Laxadyn syr 0-0-2 C

Discussio
n

Acute Coronary Syndrome

(ST Elevation Myocardial
Infarction)

Definition
Acute Coronary Syndrome (ACS) is a term for situations
where the blood supplied to the heart muscle is suddenly
blocked.
describe 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).

Classification

Non-Modifiable
Gender and Age

Family History

Modifiable
Smoking
Hypertension
Diabetes Melitus
Dyslipidemia
Obesity

Risk Factors

Diagnosis of ACS
At least 2 of the following :

1. Ischemic symptoms
2. Diagnostic ECG changes
3. Serum cardiac marker elevations

1. Ischemic Symptoms
Duration of chest pain > 20 minutes, at
substernal area
Substernal chest pain / chest discomfort
radiated to the left arm, shoulder, neck, jaw
Not fully relieved by rest or nitroglycerine
The chest discomfort may also be described
as a dull pain ,pressure, squeezing or
crushing sensation or burning sensation
Associated features including palpitation,
sweating, breathlessness, and nausea.

2. Diagnostic ECG Changes

3. Serum Cardiac Marker Elevation

CK
CK

CK-MB
CK-MB
Troponin
Troponin
T
T

Diagnosis
Signs of myocardial
ischemia
ECG
ST segmen elevation ?

No

Lab

Biochemical cardiac markers ?

No

Yes

Yes

STEMI

Acute Myocardial Infarction

( Q-wave, non-Q wave )

NSTEMI
(No ST-Segment
Elevation
Myocardial Infarction)

Unstable Angina

Therapy

Bed rest
Diet
O2 2-4 lpm via nasal prongs
Nitrat:
ISDN 10 mg or 20 mg, 2-3 a day.
ISDN 5 mg SL when chest pain.
Antiplatelet:
Aspirin 160-325 mg chewed immediately and 80-160 mg
continued indefinitely.
Clopidogrel 300-600 mg loading dose and 75 mg daily
continued
Trombolitic: (if onset < 6 hours) 1,5 million unit IV in a hour

Prognosis
KILLIP CLASSIFICATION

Class

Description

Mortality Rate
(%)

no clinical signs of heart failure

II

rales or crackles in the lungs, an

S3, and elevated jugular venous

17

pressure
III

acute pulmonary edema

30 - 40

IV

cardiogenic shock or hypotension

(systolic BP < 90 mmHg), and
evidence of peripheral

60 80

TIMI PROGNOSIS
Risk Factor

Score

Age > 65 years old

>/= 75

2
3

Total
Score

History of
angina/hipertension/DM

Risk of
Death in 30
days

0.8%

Systolic BP <100

1.6%

2.2%

Heart rate >100

4.4%

Killip II-IV

7.3%

Weight >67 kg

12.4%

Anterior MI or LBBB

16.1%

Delay treatment >4 hours

23.4%

26.8%

9-14

35.9%

THANK YOU