Cardiovascular Case

Inferior ST Elevation
Myocardial Infarction (STEMI),
Onset >12 h, Killip I,TIMI 3/14
By. Ahmad Nur Islam (C111 06
012)
Medical Faculty of Hasanuddin University, Makassar 2010

RM number
:
Name
:
Age
:
Address
:
Date administered:
Time administered

42 92 78
Mrs. D
59 years old
Jl. Toddopuli
26th July 2010
: 23.30 WITA

Chief complaint: chest pain

It occurred since 14 hours (10.00-23.30) before
hospitalization,the duration more than 5 minutes
,continuously, radiated to his left arm and shoulder. The
patient feels like stabbing on her left chest. The pain was
not relieved by resting or medication.
Shortness of breath (+) 8 hour before hospitalized,felt
while she got chest pain,it is not effected by weather,
history of shortness of breath at night (-), the patient felt
comfortable sleeping without any pillow.
Nausea (+), vomiting (+) , epigastric pain (-), sweating (+).

Fever (-), history of fever (-).

Defecation: normal
Micturition: normal
History of diseases and risk factors:
Smoking (-)
Hypertension (-)
Diabetes mellitus (-)
Heart disease in the past (+) on 2001

 General status
moderate illness/sufficient weight/conscious
Vital sign
BP
HR
RR
T

:
:
:
:

130/90 mmHg
83 x/min
20 x/min
36,80C

Regional status
Head : anemia (-), icterus (-), cyanosis(-)
Neck: JVP R+2 cmH2O
Thorax : breath sounds: bronchovesicular
additional sounds: Rh: -/-, Wh: -/ Heart : heart sounds: S1-S2 pure, regular,
murmur (-)
Abdomen : peristaltic (+), tympani,
Extremities : warm, oedema (-)

(26-07-2010)
Sinus
rhythm, BP
74/min
Inferior at
miocard
infarction

 Conclusion (26-07-2010):
Cardiomegaly

10

Echocardiograf
Fungsi sistolik global +
Segmental LV menurun, EF 33%
Hipokinetik berat midanteroseptal, anterior,
septoapical, apical ec CAD
LV dilatasi dengan IVS yang menipis ec
iskemik.
Fungsi venterikel kanan baik
Trombus + apical LV CAD

 Biochemical blood test (26-07-2010):

CK : 277 (<190)
CKMB : 35 u/l (<25)
RPG: 139 mg/dl (140)
Ureum : 26 mg/dl (10-50)
Creatinin : 0,7 mg/dl (<1,3)
GOT
: 30 u/l (<38)
GPT : 19 u/l (<41)
Tot Chol : 246 mg/dl (<200)
HDL: 35mg/dl (>55)
LDL : 175 mg/dl (<130)
TG : 105 mg/dl (<200)

 Routine blood test (26-07-2010):

WBC : 8,2x103/ul
RBC : 4,7x106/ul
HGB : 13,0 g/dl
HCT : 40,9%
PLT : 244x103/ul

Electrolyte (26-07-2010):
Sodium : 139 mmol/l (136-145)
Potassium : 4,1 mmol/l (3,5-5,1)
Chloride : 107 mmol/l (97-111)

 Inferior STEMI,
onset >12 hours, Killip I, TIMI score 3/14

 Bed rest
Loading dosage
Farmasal 80 mg (2 tablets), Plavix 75 mg (4
tablets)
O2 3-4 ltr/min

NaCl 0,9% 16 drops/min

Fasorbid 10 mg 1-1-1
Farmasal 80 mg 0-1-0
Pladogrel 75 mg 0-1-0
Lipitor 20 mg 0-0-1
Alprazolam 0,5 mg -1/2-1

 Troponin T and I

DISCUSSION

ST Elevation Myocardial
Infarction (STEMI)

 Acute coronary syndromes include:

Unstable Angina
Non ST-elevation MI (NSTEMI)
ST-elevation MI (STEMI)

Myocardial infarction rapid development

of myocardial necrosis by a critical
imbalance between oxygen supply and
demand of the myocardium

 Symptoms such as anginal chest pain,

dyspnoe, palpitation, diaphoresis.
ECG: ST segment elevation or new onset
LBBB
Enzymes: CKMB, Trop T and I

19

 Killip class I includes individuals with no clinical

signs of heart failure.
Killip class II includes individuals with rales or
crackles in the lungs, an S3, and elevated
jugular venous pressure.
Killip class III describes individuals with frank
acute pulmonary edema.
Killip class IV describes individuals in
cardiogenic shock or hypotension (measured as
systolic BP<90 mmHg), and evidence of
peripheral vasoconstriction (oliguria, cyanosis
or sweating).

Historical
Age 65-74
>/= 75
DM/HTN or Angina
Exam
SBP < 100
HR > 100
Killip II-IV
Weight < 67 kg
Presentation
Anterior STE or
LBBB
Time to treatment >
4 hrs

2 points
3 points
1 point
3 points
2 points
2 points
1 point
1 point
1 point

 Supplemental Oxygen
Hypoxemia can occur in STEMI due to
ventilation perfusion mismatch
ABG should be obtained and if saturation is
normal, oxygen therapy is not cost effective
If saturation is 90%, O2 should be given at
rates of 2-4 lits/min of 100% concentration

Antiplatelet agents
Aspirin
Integral part of initial management strategy
162 to 325 mg stat should be given as lower
doses take time to have their effect
Then continued indefinitely at a dose of 75 mg to
162 mg
In patients for whom there is concern about
bleeding, lower doses of aspirin can be used

Clopidogrel 75 mg daily
Should depend on the judgment of the riskbenefit ratio for the individual patient

Pain control
Morphine
Dose 4-8mg IV followed by 2-8 mg repeated at
intervals of 5-15 mins to achieve the desired response
or there is toxicity like hypotension, respiratory
depression or severe vomiting
Allays anxiety

Nitrates
Mechanism of action: coronary vasodilatation,
decreases ventricular preload
The only group of patients in whom these are
contraindicated are those having: suspected RV
infarction, severe hypotension esp. if accompanied by

 Beta blockers
Reduce pain, reduce need for analgesics,
reduce infarct size and reduce fatal
arrhythmias
Contraindications are: heart failure,
hypotension bradycardia and conduction
block
ACE inhibitors
Reduce mortality rates
Maximum benefit occurs in high risk patients
Reduces ventricular re-modeling after an

Thrombolytic Agents
tPA
tPA Dose : 15mg IV bolus followed by 0.75mg/kg(max
50mg) over 30mins, followed by 0.5mg/kg(max 35mg) for
60 mins
Reteplase: not superior to tPA.
Tenecteplase: better than tPA in patients in whom lysis was
done after 4hrs from onset of symptoms

Streptokinase
Streptokinase Dose : 1.5MU in 30-60 mins
Antigenic and cause allergic reactions
May be ineffective in patients who have received strepto in
the past 1 yr
Most common and major complication is bleeding

Indication
MI and ST segment elevation greater than 0.1mV in 2 contiguous ECG leads,
or new onset LBBB, who present less than 12 hours but not more than 24
hours after symptom onset

Contraindications

Any prior ICH Structural cerebral vascular lesion

Malignant intracranial neoplasm
Ischemic stroke within 3mo except acute ischemic stroke within 3hrs
Suspected aortic dissection
Active bleeding or bleeding diathesis
Significant closed head or facial trauma within 3 months

Choice of therapy
Choice of therapy For patients who present in <4hrs, choice is tPA, as the
speed of reperfusion is important
For patients who come between 4-12 hrs, strepto and tPA are equivalent
options
Of note, those patients having increased rise of ICH (like elderly with inf. AMI,
sysBP >100 and heart rate <100/min), strepto is preferable due to cost
considerations.

 Antithrombin therapy
IV UHF bolus at 60U/kg to a maximum of 4000U
followed by initial infusion of 12U/kg/hr to a max
of 1000U/hr given for 48 hours has established
efficacy in patients receiving thrombolytic
therapy
Prolonged administration may be beneficial.
Other drugs: hirudin, bivalirudin, LMWH,
fondaparinux

 Lipid Management
Post MI patients with LDL > 100 mg/dl are
recommended to be on drug therapy to try to
lower levels to <100 mg/dl
Recent data indicate that all MI patients should
be on statin therapy, regardless of lipid levels
or diet

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

THANK YOU