CASE REPORT

OCTOBER 2014

Presented By :
Ganesha
C 111 07 320

Supervisor :
Prof.DR.dr. Ali Aspar M, Sp.PD, Sp.JP(K), FIHA, FA SCC,
FINASIM, FIKA

Department of Cardiology and Vascular Medicine

Medical Faculty of Hasanuddin University
Makassar
2014
 Name : Mr. M.N
 Age : 56 years old
 Address : Kg. Jangka
 MR : 683132
 Date of Admission : October 2nd 2014

 Occupation : not working

 Chief complaint : Chest pain
 Present Illness History :
• Left chest pain felt for the past 1month and worsened ± 14
hours before admission
• Described as sharp pain that felt through to the back,
intermittently, persisted on resting, duration of pain :
> 20 minutes.
• Pain accompanied with cold sweats.
• Nauseous, with no vomit, no dypsnea on excertion, there is no
paroxysmal nocturnal dypsnea
• Patient was treated at Grestelina Hospital before getting
admitted to Wahidin Hospital with the diagnosis of STEMI Whole
Anterior onset < 12hours Killip 1, and has received trombolytic
therapy , Plavix 1x 75mg, Aspilet 1 x 80mg and Lipitor 0-0-1
 Past Illness History :
• There is past history of chest pain ± 2 years ago,
relieved with rest, with no medication
• There is past history of hypertension for the past 15
years, treated regularly
• No history of cough or difficulty of breathing
• No history of heart attack
 Personal Life History :
• There is history of alcohol consumption
(during high school)
• There is history of smoking for the past ± 40 years,
with ± 40 cigarettes per day
• No history of heart disease in the family
 General Status
• Moderate illness / Overweight / Composmentis
• Weight : 70 kg
• Height : 170 cm
• BMI : 24,22 kg/m2
 Vital Status
• Blood pressure : 140/80 mmHg
• Heart rate : 70 bpm
• Respiratory rate : 17 rpm
• Temperature : 36,7 oC
 Head : anemic (-) icteric (-)
 Neck : JVP R+2cm H2O
 Lung :
• Inspection : symmetry left=right
• Palpation : no tenderness, normal vocal fremity
• Percussion : sonor
• Auscultation : vesicular, ronchi -/-, wheezing -/-
 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 (-)
 Abdomen :
• Inspection : flat, follows breath movement
• Auscultation : peristaltic (+), normal
• Palpation : liver and spleen not palpable
• Percussion : tympani

 Extremities :
• Edema (-)
Sinus rhythm
Heart rate : 83 bpm
Axis :
Normoaxis
P Wave : 0,12 s
PR interval : 0,16 s
QRS Duration :
0,12 s
ST segment : ST
elevation on lead V1-V3

Conclusion :
Sinus rhythm, HR 83
bpm, Normoaxis, ST
elevation on
anteroseptal
 TEST RESULT NORMAL VALUE

GDS 90 mg/dL <140

TEST RESULT NORMAL VALUE
SGOT 13u/L <38
WBC 8.5 x 103/uL 4.0 – 11.0 x 103
SGPT 12 u/L <41
RBC 4.49 x 106/uL 4.0 – 6.0 x 106
Ureum 40 10-50
HGB 15.5 g/dL 12 – 16
Kreatinin 1.4 0,5-1,2
HCT 45 % 37 – 48
Troponin T 1.3 <0,05
PLT 140 x 103/uL 150 – 400 x 103
CK 312 <190
CKMB 36 <25
Natrium 143 136 - 145
Kalium 3.4 3,5 - 5,1
Klorida 109 97 - 111
Asam Urat 4.0 3,4-7,0
Result :
• Cardiomegaly, aorta
dilatatio, elangatio et
atherosclerosis
 LV Diastollic
dysfunction
 LVH
 Septoapical
Hypokinetic
 EF 55%
 STElevation Myocardial Infarction (STEMI)
Whole Anterior onset < 12 hours, KILLIP I,
post thrombolytic
 O2 4 lpm via nasal cannula
 IVFD NaCl 0,9% 500 cc/24 hours
 Arixtra 2.5mg/24hours/subcutan
 ISDN 5mg/sublingual (only during pain)
 ISDN 1mg/hour/syringe pump
 Fondaparinux 2,5mg//24hour/sc
 Atorvastasin 40mg/24hour/oral
 Clopidogrel 75mg/24hours/oral (afternoon)
 Aspilet 80mg/24hours/oral (morning)
 Captopril 12.5mg/12hours/oral
 Laxadine syr 30cc/24hours (night)
 Alprazolam 0,5mg/24hours/oral (night)
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).
 Modifiable Non-Modifiable
Smoking Gender & Age
Hypertension • Men > 45 years old
• Women > 55 years old
Diabetes mellitus
Hypercholesterolemia Family history
Obesity • Heart disease in biological
brother or father > 55 years old
Psychosocial stress • Heart disease in biological sister
or mother > 65 years old
Lack of physical activity
 • Prolonged chest pain
Ischemic Usually retrosternal location
symptoms • Dyspnea
• Diaphoresis

Diagnostic
ECG changes

Serum cardiac • Troponin-T

• CK-MB
marker • CK
elevations • Myoglobin
Hyperacute Phase Complete Evolution Old Infarct
• Non specific ST-Elevation • Specific ST-Elevation • Q-Pathologic
• T taller and wider • T inverted • ST segment isoelectric
• Q-Pathologic • T normal or inverted
 TIMI RISK SCORE FOR STEMI ODDS OF
Historical RISK SCORE DEATH BY
Age 65-74 2 points 30D*
>/= 75 3 points 0 0.1 (0.1-0.2)
DM/HTN or Angina 1 point 1 0.3 (0.2-0.3)
Exam 2 0.4 (0.3-0.5)
SBP < 100 3 points 3 0.7 (0.6-0.9)
HR > 100 2 points 4 1.2 (1.0-1.5)
Killip II-IV 2 points 5 2.2 (1.9-2.6)
Weight < 67 kg 1 point 6 3.0 (2.5-3.6)
Presentation
7 4.8 (3.8-6.1)
Anterior STE /LBBB 1 point 8 5.8 (4.2-7.8)
Time to rx > 4 hrs 1 point >8 8.8 (6.3-12)
* referenced to average mortality (95%
Risk Score = Total (0-14) confidence intervals)
 Hemodynamic
Relieve pain
stabilization

Myocardial Prevent the

reperfusionn complication
 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%.
 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
Ventricular Hemodynamic
dysfunction disturbances

Cardiogenic
Arrhythmia
shock
 MORTALITY RATE
CLASS DESCRIPTION
(%)

I No clinical signs of heart failure 6

Rales or crackles in the lungs, an S3,

II 17
and elevated jugular venous pressure

III Acute pulmonary edema 30 - 40

Cardiogenic shock or hypotension

(systolic BP < 90 mmHg), and
IV 60 – 80
evidence of peripheral
vasoconstriction