BY :

Name : Andrew Ruspanah

Nim : C111 08 188


SUPERVISOR
Pro ! "r! dr A#i Aspar $%Sp!P"% Sp!&P '()% *I+A%
*asCC% *INASI$
CAR"IO,O-Y "EPAR.$EN.
$E"ICA, *ACU,.Y O* +ASANU""IN UNIVERSI.Y
$A(ASSAR
/010
CASE REPORT
1+O,E AN.ERIOR
ONSE. 21/ +OURS (I,,IP I
PA.IEN.3S I"EN.I.Y

Name : Mrs. I

Gender : Female

Age : 59 y.o

Registration no. : 60 54 18

Date o Admission : !1"04"!01#

$%ie $om&laint :

Ches4 Pain
'resent illness %istory:

$%est &ain %as (een e)&erien*ed sin*e #

days ago and in*reasingly (e*ome %ea+y
1! %o,r (eore admitted to t%e %os&ital.
-%is &ain .as des*ri(ed as a &ress,re
sensation/ &enetrated to t%e (a*0and
does not radiated. 1istory o *%est &ain2"3.
+IS.ORY .A(IN-
4
$old 5.eat 263 .%ile *%est &ain
o**,rred/ 'al&itation 2"3
4
Na,sea 263/ +omiting 263 / e&igastri*
&ain 263/ 5%ort o (reat%ness 263/
%istory o s%ort o (reat%ness 2"3
4
$o,g% 263/ m,*,s 2"3/ Di77iness 2"3/
%eada*%e 2"3
4
8rination 9 .it%in normal limit
4
Dee*ation 9 .it%in normal limit

1istory o %y&ertension 263 sin*e

10 years ago/ (,t not on reg,ler
medi*al treatment

1istory o Dia(etes mellit,s 2"3

1istory o %eart disease 2"3

1istory o smo0ing 2"3

Family %istory o *ardio+as*,lar

disease 2"3
1istory o admitted at 5ale.angan
Maros %os&ital and %ad gi+en :
1. I:FD R; !8t&m
!. <! 4 l&m
#. As&ilet 160 mg
4. I5DN 5 mg
5. Ranitidin 1 am&=8>=i+

Moderate illness=
$ons*io,sness
-enera#
s4a4us :

?ood 'ress,re: 180=100 mm1g

',lse Rate : @8 (&m

Res&iratory Rate: !8 (&m

-em&erat,re : #6.5 0$
Vi4a#
si5n
Ph6si7a# E8amina4ion

E6e : $on>,n*ti+a anemi* 2"="3/ s*lera

i*teri* 2"="3

,ip : $yanosis 2"3

Ne79 : A:' : R " ! *m1!<

+ead and
Ne79
E8amina4ions:

Inspe74ion : 5ymmetri* let 9 rig%t

Pa#pa4ion : No mass/ no
tenderness/ +o*al remit,s let9rig%t

Per7ussion : 5onor let 9 rig%t/ l,ng"

li+er (order in I$5 :I rig%t anterior

Aus7u#4a4ion : ?reat% so,nd:

:esi*,lar. Additional so,nd : Ron*%i
"=" / B%ee7ing "="
Ches4
E8amina4ion
Ph6si7a# E8amina4ion
Ph6si7a# E8amina4ion
Cardia7 E8amina4ion

Ins&e*tion : A&e) .as not +isi(le

'al&ation : A&e) .as &al&a(le

'er*,ssion : D,ll/ normal %eart si7e

8&&er (order : let !nd I$5
?ottom (order : let 5t% I$5
Rig%t (order : rig%t &arasternalis line
;et (order : let mid*la+i*,lar line

A,s*,ltation : 1eart 5o,nds : 5 I=II &,re reg,lar

Additional so,nd : m,rm,r 2"3

Inspe74ion : Flat/ ollo.ing (reat%

mo+ement

Aus7u#4a4ion : 'eristalti* so,nd 263/

normal

Pa#pa4ion: No mass/ no tenderness/

no &al&a(le li+er and s&leen

Per7ussion : -ym&ani 263/ as*ites 2"3

A:domina#
E8amina4ion

'reti(ial edema "="

Dors,m &edis edema "="

E84remi4ies
E8amina4ion
Ph6si7a# E8amina4ion
Electrocardiography Findings

ECG Interpretation

Sinus Rhythm

Heart Rate :80 x/I

P Wave : 0,08 sec

PR interval : 0,16 sec

QRS cm!lex :0,06sec

"xis : nrmaxis

S# elevate$ at : %ea$ &1'&(

# inverte$ lea$ I, a&%, &6

)nclusin : sinus rhythm, *hle anterin micar$
in+arctin, anterlateral ischemic
Laboratorium Finding
-est Res,lt Normal +al,e
B?$ 9/98 ) 10#=,l 4.0 C 10.0 )
10#
R?$ 4/@4) 106=Dl 4.0 C 6.0 ) 106
1G? 1!/8 gr=dl 1! C 16
1$- 40/1 E #@ C 48
';- !5@) 10# =Dl 150 C 400 )
10#
$om&lete (lood *o,nt
Blood Chemistry
-est Res,lt Normal +al,e
GD5 1!! mg=dl F140
8re,m ## mg=dl 10 C 50
$reatinine No reagent F 1.#
5G<- 184 ,=l F#8
5G'- !@ ,=l
F41
-est Res,lt Normal +al,e
-ro&onin"- G!/0 Negati+e
Cardiac Enzymes
Lipid Profile
-est Res,lt Normal +al,e
$%ol. total !@8 mg=dl !00
$%ol. 1D; 46 mg=dl ;G55H 'G65
-rigliserida 66 mg=dl !00
Electrolyte
-est Res,lt Normal +al,e
Na 14# mmol=l 1#6"145
I #.9 mmol=l #.5"5.1
$l 109 mmol=l 9@"111
Radio#o56 *indin5
$ardiomegaly
2$-I: 0.6#3
.it% dilatation
aorta and
sign o l,ng
*ongestion
"ia5nosis
S. E#e;a4ion $6o7ardia#
Inar74ion 'S.E$I)
1ho#e an4erior wa## Onse4
21/ +ours (I,,IP I
$ana5emen4

<! #"4 l&m +ia Nasal $an,le

I:FD Na$l 0/9E 500**=1!%

Anti &latelet As&ilet 80 mg 80mg !"0"0 ne)t 1"

0"0

Anti &latelet $lo&idogrel @5 mg 0"4"0 ne)t 0"1"

0

Isosor(id dinitrat Iso0et 1 mg= %o,rs=s&

A$J in%i(itor rami&ril 5 mg 0"0"1

?eta (lo*0er (iso&rolol !/5 mg 0"0"1

Ranitidin am&=1!>=i+

;a)adyn syr

?en7odia7e&ine Al&ra7olam 0.5 mg 0"0"1

"ISCUSSION
ACU.E CORONARY SYN"RO$E
'S. SE-$EN. E#e;a4ion
$6o7ardia# Inar74ion)
INTRO!CTION

An a*,te myo*ardial inar*tion is

*a,sed (y ne*rosis 2irre+ersi(le3 o
myo*ardial tiss,e d,e to is*%emia/
,s,ally d,e to (lo*0age o a
*oronary artery (y a t%rom(,s.
A7u4e 7oronar6 s6ndrome

A*,te *oronary syndrome 2A$53

reers to a s&e*tr,m o *lini*al
&resentations ranging rom t%ose
or:

5-"segment ele+ation myo*ardial

inar*tion 25-JMI3

nonC5-"segment ele+ation myo*ardial

inar*tion 2N5-JMI3

,nsta(le angina
PA.+OP+YSIO,O-Y
RIS" FACTORS
#odi$iable%

Hy!ertensin

,ia-etes .ellitus

,ysli!i$emia

Sm/in0

1-esity
Non&modi$iable%

2en$er: male

"0e 34( years l$

Persnal histry +
)rnary "rtery ,isease

5amily histry +
)rnary "rtery ,isease
B1<
Diagnosti*
$riteria
$lini*al %istory o
is*%emi* ty&e *%est
&ain lasting or more
t%an !0 min,tes
$%anges in serial
J$G tra*ings
Rise and all o
ser,m *ardia*
(iomar0ers s,*% as
*reatine 0inase"M?
ra*tion and tro&onin
DIAGNOSIS
<)ord 1and(oo0 o $lini*al Medi*ine 6t% Jdition
IA'NOSE())))
No
Yes
Yes
No
A*,te Myo*ardial Inar*tion
N5-JMI
2 Non 5-"Jle+ation
Myo*ardial Inar*tion 3
8nsta(le Angina
Si5ns o m6o7ardia#
is7hemia
< Bio7hemi7a# 7ardia7
mar9ers =
ECG
Lab
S. se5men4 e#e;a4ion=
'eneral Therapy $or ACS

General :

Immediate o)ygen t%era&y 2 maintain or irst 6

%o,rs 3

Nitrogly*erin

relie *%est &ain:

As&irin

Mor&%ine 5,late

re&er,sion:

Fi(rinolyti*

'er*,taneo,s *oronary Inter+ention 2'$I3

$ontin,o,s *ardia* monitoring

Jsta(lis%ment o intra+eno,s 2I:3 a**ess

MANAGEMENT
$oronary 1eart Disease in $lini*al 'ra*ti*e
Prognosis
C#ass "es7rip4ion $or4a#i46 Ra4e
'>)
I No *lini*al signs o %eart ail,re 6
II Rales or *ra*0les in t%e l,ngs/ an
5#/ and ele+ated >,g,lar +eno,s
&ress,re
1@
III A*,te &,lmonary edema #0 " 40
I: $ardiogeni* s%o*0 or
%y&otension 2systoli* ?' F 90
mm1g3/ and e+iden*e o
&eri&%eral +aso*onstri*tion
60 C 80
(I,,IP C,ASSI*ICA.ION
.I$I C,ASSI*ICA.ION
Ris9 *a74or S7ore
Age G 65 years old !
Age G @5 years old #
1istory o
angina=%y&ertension=DM 1=1=1
5ystoli* ?' F100 #
1eart rate G 100 !
Iilli& II"I: !
Beig%t G 6@0g 1
Anterior MI or ;??? 1
Delay treatment G4%o,rs 1
Complication

5,dden Deat%

:entri*,lar 5e&tal Dee*t

1emodynami* Dist,r(an*es

$ardiogeni* s%o*0

-rom(oem(oli

Arr%yt%mia &ost 5-JMI

THANK YOU