Laporan Kasus Stemi

APRIL 2016
CASE REPORT:
ST SEGMENT ELEVATION
INFERIOR MYOCARDIAL INFARCTION
ONSET > 24 HOURS KILLIP II
Presented by:
Nurhafidah Mahfudz C111 12 058
Andi Saputri Majid C111 12 057
Andi Idil Saputra C111 12 059
Hartati Hamzi C111 12 062
Supervisor:
dr. Abdul Hakim, Sp.JP, FIHA
PATIENT IDENTITY
 Name : Mr. B
 Age : 61 years old
 Address : Mattoanging
 MR : 532990
 Date of Admission : 19/4/2016
HISTORY TAKING
 Chief complaint : Chest pain

 Present Illness History :
 Suffered since 1 day before admission
 Described as burned and compressed pain on the left side

and radiating to left arm and neck, intermittently, duration
of pain : 20-30 minutes, accompanied with cold sweat.
 The intensity is not influeced by activity or rest
 Shortness of breath (+)
 DOE (+)
 PND (+)
 Nausea (+), no vomitting

HISTORY TAKING
 Past Illness History :

 No history of hypertension
 No history of Diabetes Mellitus
 No history of alcohol consumption
 History of smoking (+)
 No history of previous chest pain and heart disease
 No family history with heart disease
 History of lung TB on 2015
RISK FACTOR
Modified Risk Factor

• Smoking
Non-modified risk factor:

• Gender : Male
• Age : 61 years
PHYSICAL EXAMINATION
 General Status
 Moderate illness / Under Nutrition/ Composmentis
 Weight : 45 kg
 Height : 161 cm
 BMI : 17.37 kg/m2
 Vital Status
 Blood pressure :120/70 mmHg
 Heart rate : 100 bpm
 Respiratory rate : 28 rpm
 Temperature : 36,5 oC
 Head : anemic (-) icteric (-)

 Neck : JVP R+2 cmH2O,
 Lung :
 Inspection : symmetry left=right
 Palpation : mass (-), no tenderness, normal vocal
fremitus
 Percussion : sonor
 Auscultation : vesicular, ronchi +/+, wheezing +/+
 Cor :
 Inspection : ictus cordis not visible
 Palpation : ictus cordis is palpable, thrill (-)
 Percussion :
 Upper border 2nd ICS sinistra
 Right border 4th ICS linea parasternalis dextra
 Left border 5th ICS linea midclavicularis sinistra
 Auscultation : heart sound I/II regular, murmur (-)

 Abdomen :
 Inspection : flat, follows breath movement
 Auscultation : peristaltic (+), normal
 Palpation : liver and spleen not palpable
 Percussion : tympani
 Extremities :
 Edema (-)
ELECTROCARDIOGRAPHY
Rhythm : sinus rhytm QRS complex : Q wave in II, III, aVF

Heart Rate : 91 bpm Duration of QRS : 0.06 sec
Regularity : reguler ST segment : elevation in II, III, aVF
P wave : 0.06 sec T wave : T inverted in II, III, aVF
PR interval : 0.16 sec
Axis : extreme right axis deviation Conclusion: STEMI inferior
LABORATORY FINDINGS
TEST RESULT Normal value
RBC 4,67x106/l 4,50-6,50x106/l
WBC 19,4 x103 /l 4,0-10,0 x 103 /l
HGB 13,91 g/dl 14,0-18,0 g/dl
HCT 43,2% 40,0-54,0 %
PLT 236x 103 /l 150-400 x 103 /l

LABORATORY FINDINGS
Test Result Normal value
GDS 115 mg/dl 140 mg/dl
Ureum 41 mg/dl 10-50 mg/dl
Creatinin 1,25 mg/dl M(<1,3);F(<1,1) mg/dl
SGOT 13 U/l <38 U/l
SGPT 9 U/l <41 U/l
Natrium 135 mmol/l 136-145 mmol/l
Kalium 4,2 mmol/l 3,5-5,1 mmol/l
Klorida 103 mmol/l 97-111 mmol/l

LABORATORY FINDINGS
Test Result Normal value

CK 31 U/l L(<190)P(<167) U/l
CK-MB 13 U/l <25 U/l
Troponin I 0,05 ng/ml <0,01 ng/ml
PT 10,9 detik 10-14 detik
aPTT 33,6 detik 22-30 detik
INR 1,05 detik --

CHEST X-RAY
Conclusion:
- CTI 0,31 (normal)
- Active pulmonary TB
- Lymphadenopathy hilar dextra
ECHOCARDIOGRAPHY
• Normal left and right ventricular systolic

function
• Concentric left ventricular hypertrophy
• Diastolic dysfunction grade I
DIAGNOSIS
1. ST Elevation Extensive Inferior Myocardial

Infarction (STEMI) onset >24 hours, KILLIP II
2. CAP, DD/ Syndrom Obstruction Post TB
3. Diastolic Dysfunction
TREATMENT
 O2 2-4 L/min via nasal cannula

 IVFD NaCl 0,9% 500 cc/24 hours
 Aspilet 160 mg (loading dose), maintenance 1x80 mg tab
 Clopidogrel 300 mg(loading dose), maintenance 1x75 mg
tab
 Captopril 12,5 mg/12jam/oral
 Bisoprolol 1.25mg/24jam/oral
 Nitroglycerin 1mg/jam/ SP
 Atorvastatin 40mg/24 hours/oral
 Arixtra 2,5 mg/24 hours/subcutaneous
 Laxadine syr 0-0-2 tsp
 Alprazolam 0,5 mg 0-0-1
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).
ACS Classification
20
Acute Coronary Syndrome

A. Unstable angina pectoris
B. NSTEMI
C. STEMI
Introduction
• Myocardial ischemia is caused by imbalance

between myocardial oxygen supply and
myocardial oxygen consumption.
• Myocardial infarction (MI) is the rapid
development of myocardial necrosis.
European Heart Journal. Guidelines on the management of stable angina pectoris

Regions of the Myocardium
Lateral
I, AVL,V5-V6
Inferior
II, III, aVF Anterior / Septal
V1-V4
Pathophysiology
RISK FACTORS
Modifiable Non-
Modifiable
CLINICAL PATHWAY
WHO DIAGNOSTIC CRITERIA
• Prolonged chest pain

Ischemic Usually retrosternal location
symptoms • Dyspnea
• Diaphoresis
Diagnostic • Inverted T wave

• ST segment depression or elevation
ECG changes • Pathological Q wave
Serum cardiac • Troponin-T atau I

• CK-MB
marker • CK
elevations • Myoglobin
ISCHEMIC SYMPTOMS
ECG CHANGES
Hyperacute Phase Complete Evolution Old Infarct

• Non specific ST- • Specific ST-Elevation • Q-Pathologic
Elevation • T inverted • ST segment isoelectric
• T taller and wider • Q-Pathologic • T normal or inverted
CARDIAC BIOMARKERS
GOAL OF TREATMENT
Relieve pain Hemodynamic

stabilization
Myocardial Prevent the

reperfusion complication
Reperfusion Therapy for Patients with STEMI
*Patients with cardiogenic shock or severe heart failure initially seen at a non–PCI-capable hospital should be transferred for cardiac
catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). †Angiography and
revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.
- Reperfusion Therapy -
Thrombolitik
ALTEPLASE
Alteplase 15 mg bolus iv.
50mg iv in 30minutes
35mg iv in 60minutes
TREATMENT
Bisoprolol Clinical Study shows:
-Limit area of MI
Relieve symptom -re-infarction risk decrease
NTG -prolong life span
Vasodilatation
-Plaque stabilization
-LDL decrease
target: <70mg/dl Atorvastatin -Anti-remodelling
-decrease mortality
Captopril
TREATMENT
 O2 2-4 L/min via nasal cannula

 IVFD NaCl 0,9% 500 cc/24 hours
 Aspilet 160 mg (loading dose), maintenance 1x80 mg tab
 Clopidogrel 300 mg(loading dose), maintenance 1x75 mg
tab
 Captopril 12,5 mg/12jam/oral
 Bisoprolol 1.25mg/24jam/oral
 Nitroglycerin 1mg/jam/SP
 Atorvastatin 40mg/24 hours/oral
 Arixtra 2,5 mg/24 hours/subcutaneous
 Laxadine syr 0-0-2 tsp
 Alprazolam 0,5 mg 0-0-1
ACC/AHA 2007 recommendation:
Loading: Aspirin 300mg Decrease mortality
Clopidogrel 300mg Decrease re-infarction rate
CURE study reported:

Maintanance:
Aspirin 80mg+Clopidogrel 75mg (for1year)
decrease 20% mortality risk,

infark myocardial non fatal,
stroke
COMPLICATION
PROGNOSIS
KILLIP CLASSIFICATION
CLASS DESCRIPTION MORTALITY RATE (%)
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

IV (systolic BP < 90 mmHg), and evidence 60 – 80
of peripheral vasoconstriction
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What are the symptoms of ST segment elevation inferior myocardial infarction?

What are the symptoms of ST segment elevation inferior myocardial infarction?

What are the diagnostic criteria for ST segment elevation myocardial infarction?

What are the diagnostic criteria for ST segment elevation myocardial infarction?

APRIL 2016

 Chief complaint : Chest pain

 Described as burned and compressed pain on the left side

 Shortness of breath (+)

 Nausea (+), no vomitting

 Past Illness History :

Modified Risk Factor

Non-modified risk factor:

 Head : anemic (-) icteric (-)

 Right border 4th ICS linea parasternalis dextra

 Left border 5th ICS linea midclavicularis sinistra

 Auscultation : heart sound I/II regular, murmur (-)

Rhythm : sinus rhytm QRS complex : Q wave in II, III, aVF

TEST RESULT Normal value

RBC 4,67x106/l 4,50-6,50x106/l

WBC 19,4 x103 /l 4,0-10,0 x 103 /l

HGB 13,91 g/dl 14,0-18,0 g/dl

HCT 43,2% 40,0-54,0 %

PLT 236x 103 /l 150-400 x 103 /l

Test Result Normal value

GDS 115 mg/dl 140 mg/dl

Ureum 41 mg/dl 10-50 mg/dl

Creatinin 1,25 mg/dl M(<1,3);F(<1,1) mg/dl

SGOT 13 U/l <38 U/l

SGPT 9 U/l <41 U/l

Natrium 135 mmol/l 136-145 mmol/l

Kalium 4,2 mmol/l 3,5-5,1 mmol/l

Klorida 103 mmol/l 97-111 mmol/l

Test Result Normal value

CK-MB 13 U/l <25 U/l

Troponin I 0,05 ng/ml <0,01 ng/ml

PT 10,9 detik 10-14 detik

aPTT 33,6 detik 22-30 detik

INR 1,05 detik --

• Normal left and right ventricular systolic

1. ST Elevation Extensive Inferior Myocardial

2. CAP, DD/ Syndrom Obstruction Post TB

 O2 2-4 L/min via nasal cannula

Acute coronary syndromes

Acute Coronary Syndrome

• Myocardial ischemia is caused by imbalance

European Heart Journal. Guidelines on the management of stable angina pectoris

• Prolonged chest pain

Diagnostic • Inverted T wave

Serum cardiac • Troponin-T atau I

Hyperacute Phase Complete Evolution Old Infarct

Relieve pain Hemodynamic

Myocardial Prevent the

Alteplase 15 mg bolus iv.

 O2 2-4 L/min via nasal cannula

CURE study reported:

decrease 20% mortality risk,

I No clinical signs of heart failure 6

Rales or crackles in the lungs, an S3,

III Acute pulmonary edema 30 - 40