CASE STUDY

Anterior ST-Elevated Myocardial Infarction

Hypertensive Heart Disease

Jovi Pardomuan Siagian, S. Ked

I11112008/I4061152027

Supervisor
Letnan Kolonel CKM dr. Prihati Pujowaskito, Sp. JP(K), MMRS

Department of Cardiology
Dustira Army Hospital Cimahi
Tanjungpura Faculty of Medicine
2018
Identity

 Name Mr. AM
 Age 49 years old
 Medical Record 540441
 Method of Payment BPJS
 Date of Admission 7 April 2018, 21:08
History Taking

 Chief complaint
 Chest pain
 Pain was felt since 6 hours prior to admission
 Radiated to left back and upper part of left arm
 Did not subside with rest

 Pain was accompanied with cold sweats

 Referred from Mitra Kasih General Hospital

 Pain subsided upon taking nitrate
 CKMB at 263 mg/dL
History Taking

 History of past illnesses

 Hypertension (+)
 Was diagnosed since 4 years ago
 Systolic blood pressure was around 140-150 mmHg
 On valsartan
 Medication not taken regularly

 Diabetes mellitus (-)

 Hypercholesterolemia unknown
 Similar complaints previously (-)
History Taking

 Habits and Lifestyle

 Smoking (+)
 Ceased 4 years ago
 Used to smoke about 1 pack/day

 Eating food with high fats (-)

 Sedentary daily activities
Physical Examination

 Vital signs
 Blood pressure 140/80 mmHg
 Heart rate 100 beats/minute
 Respiratory rate 28 breaths/minute
 Temperature 36,9oC
Physical Examination

 Eyes
 Anemic conjunctivae (-)
 Yellow sclerae (-)
 Neck
 Neck vein distention (-)
 Hepatojugular reflux (-)
 Jugular venous pressure 5 + 2 cmH2O
 Abdomen
 Inspection
 Flat
 Auscultation
 Normal bowel sounds
 Percussion
 Tympany on all parts of abdomen
 Palpation
 Tenderness (-)
 No palpable mass
Physical Examination

 Thorax
 Inspection
 Symmetrical chest inflation
 No visible ictus cordis
 No intercostal retraction
 Palpation
 Ictus cordis palpable on 6th intercostal space, left midclavicular line
 Percussion
 Resonant on all parts of both lungs
 Auscultation
 Crackles (-), wheezing (-)
 Regular 1st and 2nd heart sounds
 No third heart sound nor murmur

 Extremities
 Warm extremities
 Capillary refill time < 2 seconds
 Edema (-)
Electrocardiogram
Sinus rhythm P-wave ST-elevation in leads I, aVL, V2-V5
Heart rate ~ 83 bpm PR interval ST-depression in leads II, III & aVF
Normal axis QRS complex
Laboratory Values
Basic Hematology

Items Result Unit Normal range

Hemoglobin 14,8 g/dL 13,0 – 18,0
Erythrocyte 4 900 000 /µL 4 000 000 – 5 500 000
Leukocyte 15 100 /µL 4 000 – 10 000
Hematocrit 41,7 % 38,0 – 51,0
Thrombocyte 206 000 /µL 150 000 – 400 000
Laboratory Values
Red Cell Indices

Items Result Unit Normal range

MCV 85,1 fL 75,0 – 100,0
MCH 30,2 pg 25,0 – 32,0
MCHC 35,5 g/dL 32,0 – 36,0
RDW 13,1 % 10,0 – 16,0
Laboratory Values
Differential Counting

Items Result Unit Normal range

Basophiles 0,3 % 0,0 – 1,0
Eosinophiles 0,1 % 1,0 – 4,0
Neutrophiles 70,4 % 50,0 – 80,0
Lymphocytes 21,3 % 25,0 – 50,0
Monocytes 7,9 % 4,0 – 8,0
Laboratory Values
Chemistry & Immunology

Items Result Unit Normal range

Urea 36 mg/dL 10 – 50
Creatinine 1,1 mg/dL 0,9 – 1,3
Triglyceride 112 mg/dL 60 – 200
LDL 130 mg/dL < 115
HbsAg Non-reactive Non-reactive
Assessment & Planning

 Assessment 1
 Anterior ST-Elevated Myocardial Infarction
 Hypertensive Heart Disease

 Planning 1
 IVFD Normal Saline
 Inj. Enoxaparin 60 mg/12 h
 PO Atorvastatin 40 mg qd
 PO Clopidogrel 75 mg qd
 PO Acetylsalicylic acid 100 mg qd
 PO Ramipril 2,5 mg qd
 PO Bisoprolol 2,5 mg qd
 PO Nitroglycerin 2,5 mg bid
 Coronary angiography
Angiography

Coronary Artery Comment

Right coronary artery No pathologies found
Left main coronary artery No pathologies found
Left anterior descending artery Total occlusion in proximal part
of the vessel, suggesting ciritical
stenosis with thrombus
Left circumflex artery No pathologies found
Assessment 2
Single vessel coronary artery disease
Culprit lession in left anterior descending artery
Planning 2

Non-pharmacological Pharmacological
 Bare-metal stenting in left anterior  PO Atorvastatin 40 mg qd
descending artery
 PO Clopidogrel 75 mg qd
 2,75 x 16 mm at 10 atm
 PO Acetylsalicylic acid 100 mg qd
 Residual stenosis 0
 PO Ramipril 2,5 mg qd
 TIMI flow 3
 PO Bisoprolol 2,5 mg qd
 Control risk factors
 PO Nitroglycerin 2,5 mg bid
 Smoking cessation
 Avoid high-fat diet
 Increase compliance to
hypertension therapy
Prognosis

 Quo ad vitam Dubia ad bonam

 Quo ad functionam Dubia ad bonam
 Quo ad sanactionam Dubia ad bonam