ST SEGMENT ELEVATION

MYOCARDIAL INFARCTION
(STEMI)
PRESENTED BY : NUR RAISAH ULFAH- C 111 09382

SUPERVISED BY :Prof. dr. Peter Kabo, PhD, Sp. FK, Sp. JP (K),
FIHA, FASCC
Department of Cardiology and Vascular Medicine
Medical Faculty of Hasanuddin University
Makassar
2014

PATIENT IDENTITY

ID Number
: 651739
Name
: MR TP
Age
: 68 years old
Gender
: Male
Date of Admission
: November 14th 2014

HISTORY TAKING
Chief complaint : Chest pain
History of present illness
Occurred 3 weeks ago before entering the hospital and was
advancing in last couple of days so that patient have been referred
to the RSWS from torajas hospital cause there was no significant
improvement of symptoms.
At the beginning, Chest pain is suddenly felt in a substernal area,
pain is like crushed with heavy load. The pain wasnt radiated.
Duration of pain continuously more than 20 minutes with a cold
sweating, and not relieved by rest then increased by activity.
There are shortness of breath, nausea and vomiting, and so
complain about a heart burn. Patient didint have a fever and no
previous history of fever.
Defecation and urination : normal

HISTORY OF DISEASE
# Past Ilness history
No History of Hypertension
No History of DM
No History of high blood cholesterol
No History of previous heart disease
No History of epigastric pain
No History of asthma
# Family history
No family history of heart disease
# Personal history:
History of smoking one pack each day for more 30
years.
History of drinking alcohol, once in a week.

RISK FACTOR
Modifiable

- Drink alcohol
- Smoker

Non
Modifiable
- Gender : male (+)
- Age : 68th years old (+)

PHYSICAL EXAMINATION
General
status
Moderate
illness/well
nourished/compos
Vital
mentis

sign

BP: 120 / 90 mmHg

HR: 72 x/min
RR: 28 x/min
T : 36.80 C

REGIONAL STATUS
Head Examination
Eyes : anemia (-), icterus (-)
Lip
: cyanosis (-)
Neck : lymphadenopathy (-), JVP R+3 cmH2O
Thoracal Examination
Inspection
: symetric, normochest
Palpation
: mass (-), tenderness (-), VF R=L
Percussion
: sonor
Auscultation
: breath sound
:
bronchovesicular,
there are minimally ronchi in a basal lung,
wheezing -/-

REGIONAL STATUS

Heart Examination
Inspection : IC wasnt
visible
Palpation
: IC wasnt
palpable
Percussion : normal
heart size
Upper border: left 2nd ICS
Lower border
: left 5th
ICS
Right border : right
parasternalis line
Left border : left axillaris
anterior line
Auscultation : Regular of
I/II heart sound, murmur
(-)

Abdominal
Examination
Inspection : flat and
following breath
movement
Auscultation :
peristaltic sound (+) ,
normal
Palpation : liver and
spleen unpalpable
Percussion : tympani,
ascites (-)
Extremities
Oedema : pretibial (-),
dorsum pedis (-)

ELECTROCARDIOGRAPHY
(ECG)

INTERPRETATION
Rhythm : Sinus Rhythm
Heart rate : 84 bpm
Regularity : regularly
Axis
: Normoaxis, 30o
P wave : 0.08 sec
PR interval : 0.16 sec
QRS complex: duration 0.08 sec,
configuration q patologis at I, aVL
ST Segment: ST elevation at V2, V3, V4, V5
ST depresi at II, III, aVF
T wave : Normal
Conclusion : Sinus Rhythm, NormoAxis, Infark whole
anterior wall, Ischemic inferior, Old miocard infark high
lateral.

WBC
: 10,3 x 103
HGB
: 12,5 g/dl
HCT
: 36.8 %
RBC
: 4.04 x 106 /mm3
PLT : 437 x 103 /mm3
Cardiac enzyme
CK
: 84 u/L
CK MB : 6,7 u/L
Troponin T : 0,17u/L
Electrolyte
Sodium
:142 mmol/l
Potassium : 3,6 mmol/l
Chloride
: 111 mmol/l

Blood chemistry

Complete blood

LABORATORY EXAMINATION
GDS
: 105 mg/dl
SGOT
: 30 u/l
SGPT
: 56 u/l
Ureum
: 18
Creatinin : 1,0
PT
: 10,9
APTT
: 26,7
Total Cholesterol :
209mg/dl
HDL
: 31 mg/dl
LDL
: 143 mg/dl
Triglyseride : 162 mg/dl

Planning

EKG everyday
Echocardiography
Ro Thorax
Coronary
Angiography

WORKING DIAGNOSIS
Recent STEMI Anterior, KILLIP II

MANAGEMENT

O2 2 LPM (via nasal canule)

Cardiac Diet
IVFD NaCl 0,9% loading 500 cc/24 hours
Anti Koagulan
Fondaparinux (Arixtra) 2,5 mg every 24 hours subcutan.

Isosorbid Dinitrat
Farsorbid 10 mg every 8 hours
Farsorbid 5 mg sublingual (pain attack)
Anti Platelet Aggregation
Loading Aspilet 160 mg, maintenance 80 mg every 24 hours
Loading Clopidogrel 300mg, maintenance 75 mg every 24 hours
Anti cholesterol
HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg)
Diuretik
Furosemide 40 mg every 12 hours intravena.
Laxative
Laxadin syrup 1 x 2 cth
Anti Anxietas
Alprazolam 0,5 mg every 24 hours in night.

DISCUSSION
ACUTE CORONARY
SYNDROME
ST SEGMENT ELEVATION MYOCARDIAL
INFARCTION

DEFINITION
Acute Coronary Syndrome (ACS) is a term for situations
where the blood supplied to the heart muscle is suddenly
blocked.
STEMI is a clinical syndrome defined by characteristic
symptoms of myocardial ischemia in association with
persistent electrocardiographic (ECG) ST elevation and
subsequent release of biomarkers of myocardial necrosis.

ANATOMY

CAD
Stable
Angin
a
Pectori
s

ACS

UAP

NSTE
MI

STEMI

PATHOPHYSIOLOGY

Lipid transport disorder

Inflamation

Plaque deposition

Stable plaque

Erosion
Thrombus

Stable angina pectoris

Thrombosis

Plaque rupture
Acute coronary syndrome:
Unstable angina
Myocardial infarction :
- Non Q waves
- Q waves

RISK FACTOR FOR ACS

DIAGNOSIS OF CHEST PAIN

1
poin
t

Retrostern
al or
substernal
chest pain

1
poin
t

Increased
by activity
or
emotion

1
poin
t

Relieved
by resting
or nitrate
SL

3 point typical chest pain

Tend to be Stable Angina Pectoris than Acute Coronary Syndrome

2 point atypical chest pain

Tend to be Acute Coronary Syndrome than Non Cardiac
Chest Pain

1 point or none non cardiac chest pain

DIAGNOSIS OF ACS
At least 2 of the following:

1. Ischemic symptoms
2. Diagnostic ECG changes
3. Serum cardiac marker
elevations

ALGORITMA
Signs of myocardial
ischemia
ECG
ST segmen elevation
?

No

Lab

Biochemical cardiac
markers ?

No

Yes

Yes

STEMI
Acute Myocardial
Infarction
( Q-wave, non-Q wave )

NSTEMI
(No ST-Segment
Elevation
Myocardial Infarction)

Unstable Angina

INITIAL TREATMENT
Fixing the chest pain and fearness

Bed rest
Diet
O2 2-4 lpm via nasal prongs or face mask
Sublingual/oral/IV nitroglycerine
Antiplatelet: aspirin and clopidogrel
Morfin/petidine
Diazepam 2-5mg/8 hour

Stabilizing the hemodynamic (blood pressure and

peripheral pulse control)
-blocker if there is no contraindication
Calcium channel blocker (CCB)
ACE-Inhibitor

Reperfusion of the myocard

Initial Treatment

Vol. 61, No. 4, 2013 2013

F/AHA STEMI Guideline: Full Text January 29, 2013:e78140

COMPLICATION
Arrythmia

Heart failure

Cardiogenic
shock

Rupture of
ventricle
septum/wall

Rupture of
chordae tendineae

Pericarditis

Tromboemboli

Prognosis
KILLIP CLASSIFICATION
Class
I
II
III

IV

Description
No clinical signs of heart
failure
Rales or crackles in the
lungs, an S3, and elevated
jugular venous pressure
Acute pulmonary edema
Cardiogenic shock or
hypotension (systolic BP <
90 mmHg), and evidence
of peripheral
vasoconstriction

Mortality Rate
(%)
6
17
30 - 40

60 80

Prognosis TIMI SCORE

Historical
Age 65-74
>/= 75

2 points
3 points

DM/HTN or Angina

1 point

Exam
SBP < 100

3 points

HR > 100

2 points

Killip II-IV

2 points

Weight > 67 kg

1 point

Presentation
Anterior STE or LBBB

1 point

Time to treatment > 4

hrs

1 point

Risk Score = Total

(0-14)

Total
Score

Risk of
Death in
30 days

0
1
2
3
4
5
6
7
8
9-14

0.8%
1.6%
2.2%
4.4%
7.3%
12.4%
16.1%
23.4%
26.8%
35.9%