STEMI INFERIOR POSTERIOR

ONSET 12 HOURS KILLIP I

Presented By :
xxx
Supervisor :
xxxx
Department of Cardiology and Vascular Medicine
Medical Faculty of Hasanuddin University
Makassar
2015

PATIENT IDENTITY
Name

: Mr. M

Age

: 52 years old

Gender

: Male

Address

: BTP

MR

: 515400

Date of Admission : 20th June 2015

HISTORY TAKING
Chief complaint : Chest pain
Present Illness History :
Left chest pain felt since morning before admission while the

patient is praying.
Described as compressed pain and radiating to the left arm,
continuously, duration of pain more than 2 hours.
Cold sweat during the chest pain
Shortness of breath (-), and nausea (-), Cough (-), Paroxysmal
Nocturnal Dyspnea (-), Dyspnea on Effort (-) , Orthopnea (-)
Patient soon consumed Nitrate sublingual but not feeling better.
Patient went to Mamuju Hospital before getting admitted to
Wahidin Hospital with the diagnosis of IMA Inferior, and has
received treatment such as Fluxum 0.4cc/subcutaneous, Aspilet
loading 160mg/oral, Clopidogrel loading 300mg/oral.

HISTORY TAKING
Personal Life History :
There is past history of chest pain 1 year ago,

relieved with rest and with medication

History of high cholesterol since 2 years ago,
doesnt take medication regularly
History of smoking since 12 years ago, 1 packs per
day
No history of hypertension
No history of diabetes mellitus
No history of heart attack
No history alcohol consumption
No history of heart disease in the family

RISK FACTOR
Modified Risk Factor
Hypercholesterolemia
Smoking

Non-modified risk factor

Gender : Male
Age : 52 years

PHYSICAL EXAMINATION
General Status
Moderate illness / Overweight / Compos mentis
Weight

: 67 kg

Height

: 170 cm

BMI

: 23,18 kg/m2

Vital Status
Blood pressure
Heart rate

: 88 bpm

Respiratory rate
Temperature

:120/80 mmHg
: 20 rpm
: 36,5 oC

PHYSICAL EXAMINATION
Conjunctiva anemic (-/-), icteric (-/-)
JVP R+1 cmH2O (300)
Vesicular breath sound, ronchi (-/-), wheezing (-/-)
Heart sound 1/2 reguler, murmur (-)
Peristaltic (+) normal, Ascites (-)
Extremity edema (-/-) warm acral.

ELECTROCARDIOGRAPHY
Sinus rhythm
Heart rate : 88
bpm
Axis : normoaxis
PR interval : 0,12
s
Duration QRS :
0,08 s
ST segment
:
ST elevation on
lead II, III, aVF
Conclusion :
Sinus rhythm,
Inferior Acute
Myocardial
Infarction

ELECTROCARDIOGRAPHY
Sinus rhythm
Heart rate : 88
bpm
Axis : normoaxis
PR interval : 0,12
s
Duration QRS :
0,08 s
ST segment
:
ST elevation on
lead II,III,aVF, V8V9
Conclusion :
Conclusion: Sinus
rhythm,
Inferoposterior
Acute Myocardial
Infarction

LABORATORY RESULTS
TEST

RESULT

NORMAL
VALUE

TEST

RESULT

NORMAL
VALUE

WBC

12,6 x 10 /uL

4.0 10.0 x 10

RBC

4,87 x 10 /uL

4.0 6.0 x 10

HGB

14,4 g/dL

12 18

HCT

42%

37 48

PLT

337 x 10 /uL

150 400 x 10

PT

10,8 s

10 - 14

APTT

28,8 s

22,0 - 30,0

INR

1,04

3
6

GDS

107 mg/dL

<140

SGOT

211 u/L

<38

SGPT

64 u/L

<41

Ureum

28 mg/dL

10-50

Kreatinin

0,8 mg/dL

0,5-1,2

CK

2664,00 u/L

<190

CKMB

239 u/L

<25

Trop I

> 10.0

<0.01

Natrium
Kalium

144 mmol/L
4,3 mmol/L

136 - 145
3,5 - 5,1

Klorida

109 mmol/L

97 - 111

Asam Urat

5,2 mg/dL

3,4-7,0

LABORATORY RESULTS
TEST

RESULT

NORMAL VALUE

Total Cholesterol

180 mg/dl

200

HDL

32 mg/dl

> 55

LDL

127 mg/dl

< 130

TRIGLYCDERIDE

170 mg/dl

200

CHEST X-RAY

Result :
Cardiomegaly (CTI
index : 0.61) with
dilatation aorta

DIAGNOSIS
ST Elevation Myocardial Infarction (STEMI)

Inferoposterior onset 12 hours, KILLIP I

INITIAL TREATMENT
Bed rest
Oxygen 4 lpm
IVFD NaCl 0,9% 500 cc/24 hours
Statin

: Atorvastatin 40 mg 0-0-1
Thrombolytic : Streptokinase 1.5million
unit/hour in
dextrose 5%
Nitrate
: Farsorbid 3x10 mg tab
ACEI
: Captopril 3x12.5mg tab
Lactulose
: Laxadine syr 0-0-2 tsp
Anti anxietas : Alprazolam 0,5 mg 0-0-1

ELECTROCARDIOGRAPHY POST
TROMBOLYTIC

PLAN
Transfer to CVCU
Echocardiography
Coronary Angiography

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

INTRODUCTION

Unstable
Angina
Non
occlusive
thrombus
Non specific
ECG
Normal
cardiac
enzymes

NSTEMI

Occluding
thrombus
sufficient to cause
tissue damage &
mild
myocardial
necrosis
ST depression +/T wave inversion
on
ECG
Elevated cardiac
enzymes

STEMI
Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms

Pathophysiology

Pathophysiology

ATHEROSCLEROSIS OF CORONARY
ARTERY

RISK FACTORS

Modifiable
Smoking
Hypertension
Diabetes mellitus
Hypercholesterolemia
Obesity
Psychosocial stress
Lack of physical
activity

NonModifiable
Gender & Age
Men > 45 years old
Women > 55 years
old

Family history
Heart disease in biological
brother or father > 55
years old
Heart disease in biological
sister or mother > 65
years old

DIAGNOSTIC CRITERIA
Ischemic
symptoms

Prolonged chest pain

Usually retrosternal location
Dyspnea
Diaphoresis

Troponin-T
CK-MB
CK
Myoglobin

Diagnostic
ECG
changes
Serum
cardiac
marker
elevations

ISCHEMIC SYMPTOMS

ECG CHANGES

Hyperacute
Phase

Complete
Evolution

Non specific STElevation

T taller and wider

Specific STElevation
T inverted
Q-Pathologic

Old Infarct
Q-Pathologic
ST segment
isoelectric
T normal or inverted

CARDIAC BIOMARKERS

GOAL OF TREATMENT
Relieve pain

Hemodynam
ic
stabilization

Myocardial
reperfusion

Prevent the
complication

INITIAL TREATMENT
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%.

INITIAL TREATMENT
Morphine 2-5mg iv (can be administered again in

5-30 minutes later)

Fibrinolytic therapy:
Streptokinase 1.5million units iv
Actilyse 0.75mg/kg weight body
Anticoagulation therapy:
Low Molecular Weight Heparins (Fluxum)

0.4cc/sc for up to 8 days post-MI.

Unfractionated heparin
Anti Hypertension Drugs
Lipid Lowering Agents

COMPLICATIONS
Ventricular
dysfunction

Hemodynam
ic
disturbances

Cardiogenic
shock

Arrhythmia

PROGNOSIS
KILLIP CLASSIFICATION
CLASS

DESCRIPTION

MORTALITY RATE
(%)

No clinical signs of heart

failure

II

Rales or crackles in the lungs,

an S3, and elevated jugular
venous pressure

III

Acute pulmonary edema

30 - 40

IV

Cardiogenic shock or
hypotension (systolic BP < 90
mmHg), and evidence of
peripheral vasoconstriction

60 80

6
17

THANK YOU