ST Elevation Myocardial Infarction (STEMI)

Inferoposterior Onset <12 Hours

By:
Krisnawati Ponggalunggu
C111 11 264
Supervisor :
Dr. dr. Khalid Saleh, Sp.PD-KKV, FINASIM

PATIENTS IDENTITY

Name
: Mr. B
Gender
: Male
Age
: 55 years old
Occupation
: Police
Registration no. : 740809
Date of Admission : 11/01/2016

History Taking
Chief Complaint:
Chest pain
Guided Anamnesis:
Occured about 9 hours before admitted to the hospital. The chest
pain was felt suddenly during rest. The pain was felt like
compressed pain and radiated to the the back. The duration of the
chest pain is about 30 minutes. The pain was also associated
with cold sweat. The history of chest pain before was denied.
Short of breathness during laying down was denied, no history of
coughing, fever, nausea and vomiting or epigastric pain. History
of short of breathness was also denied.
Defecation and urination were normal.

Past Illness History

History of hypertension denied

History of Diabetes Mellitus denied
No history of cardiovascular disease before
Smoking (+), about 1 pack a day

Risk Factors
Non-Modified Risk Factor :
Gender Male
Age > 45 years old
Modified Risk Factor :
Smoking (+) 1 pack a day

Clinical Examination
GENERAL STATE
Moderate illness/normo weight/conscious
VITAL SIGN
- Blood pressure : 110/70 mmHg
- Pulse: 86 times/min
- Breathing : 20 times/min
- Temperature : 36,6C (Axilla)

Head Examination

Eyes : anemic -/-, icterus -/-, cyanosis -/

Neck : tumor mass (-), tenderness (-),
JVP R+2 cmH2O, trachea deviation (-)
Chest Examination

Inspection
: symmetric R=L

Palpation
: mass (-), tenderness (-), VF R=L

Percussion
: sonor R=L
lung-hepar border=right ICS IV
Right back lung border = right CV th VIII

Left back lung border = left CV th IX

Auscultation : breath sound : vesicular
additional sound : ronchi -/- wheezing -/-

Cardiac Examination
Inspection
: heart apex was not visible
Palpation
: heart apex was palpable
Percussion
:
Upper heart border :ICS II Linea parasternalis sinistra
Heart left border : ICS V Linea aksilaris anterior sinistra
Heart right border : ICS IV Linea parasternalis dextra
Auscultation
: Regular of I/II heart sound,
murmur (-)

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

: pretibial -/-, dorsum pedis -/-

ELECTROCARDIOGRAM

Rhythm
Heart Rate
Regularity
P wave
PR interval
Axis

: sinus rhytm
: 75 bpm
: reguler
: 0.08 sec
: 0.24sec
: Normoaxis

Duration of QRS : 0.08 sec

ST segment : elevation in II,III, aVF, v7,
v8;,
v2R-v4R, depression in V2-V6,
T wave
: normal T wave

INTERPRETATION
Rhythm
: sinus rhytm
Heart Rate : 75 bpm
Regularity : reguler
P wave
: 0.08 sec
PR interval : 0.24sec
Axis
: Normoaxis
Duration of QRS : 0.08 sec
ST segment : elevation in II,III, aVF, v7, v8, v2R-v3R; depression
in V2-V6
T wave
: normal T wave

Conclusion :
STEMI inferoposterior
RV Infarction
AV Block 1st degree

LABORATORY FINDINGS
TEST

RESULT

WBC

15,1 x 103

RBC

NORMAL

NORMAL

TEST

RESULT

4.0 10.0 x 103

Troponin I

>10,0

<0,01

4,09 x 106

4.0 6.0 x 106

CK

1720

<190

HGB

13,1

14 18

CKMB

69,5

<25

HCT

38

37 48

Natrium

137

136 145

PLT

205 x 103

150 400 x 103

Kalium

3,6

3,5 - 5,1

PT

11

10 14

Klorida

107

97 111

APTT

26,3

22,0 - 30,0

Asam Urat

4,3

3,4-7,0

INR

1,06

1,00

Kolesterol total 234

200

GDs

108

<110

Kolesterol HDL 54

>55

SGOT

26

<38

Kolesterol LDL 158

<130

SGPT

35

<41

Trigliserida

200

Ureum

39

10-50

Kreatinin

0,89

0,5-1,2

VALUE

110

VALUE

CHEST X-RAY
Conclusion:
Cardiomegaly
with signs of
pulmonary
congestive

WORKING DIAGNOSIS
ST Elevation Myocardial Infarction
(STEMI) Inferoposterior onset
<12hours
Right Ventricle Infarction

THERAPY

O2 2-4 liters/minute/NC

IVFD NaCl 0,9 % 500cc/24 hours

Fibrinolitik : Streptokinase 1.500.000 units in Dextrose 5%, finished in 60

minutes

Antiplatelet

: Aspilet loading 160mg 80 mg/24hours/oral

Clopidogrel loading 300mg 75 mg/24hours/oral

Anti coagulation : Enoxaparin 60 mg/24hr/SC

Simvastatin 20 mg 0-0-1

Laxadine syr 0-0-2 cth

Alprazolam 0,5 mg 0-0-1

DISCUSSION :

Acute Coronary Syndrome

(ST-Elevation Myocard Infarction)

DEFINITION
Myocardial infarction is myocardial
tissue damage caused by imbalance
between myocardial oxygen supply and
myocardial oxygen consumption.
Acute coronary syndromes include :

ST-elevation MI (STEMI)
Non ST-elevation MI ( NSTEMI)
Unstable Angina

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

RISK FACTORS
Modifiable

Pathophysiology

ATHEROSCLEROSIS OF CORONARY
ARTERY

SYMPTOMS
Typical

DIAGNOSIS
History taking

WHO Diagnostic
Criteria
Clinical history of ischaemic type
chest pain lasting >20 minutes
Changes in serial ECG tracings
Rise and fall of serum cardiac
biomarkers such as creatinine
kinase-MB fraction and troponin

http://en.wikipedia.org/wiki/Myocardial_infarction

Diagnosis

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

Treatment

Oxygen
Nitrate
Anti platelet agent
Anti koagulan
Morphine / pethidine
Trombolitic
-blocker
ACE inhibitors
Lipid lowering agent

Surgical
revascularization
PTCA (percutaneous
transluminal coronary
angioplasty)
CABG (coronary artery
bypass grafting)

Kabo P. Bagaimana menggunakan obat-obat kardiovaskular secara rasional. 2010

Prognosis
KILLIP CLASSIFICATION
Clas
Description
s
I
no clinical signs of heart
failure
II
rales or crackles in the lungs,
an S3, and elevated jugular
venous pressure
III
acute pulmonary edema
IV
cardiogenic shock or
hypotension (systolic BP < 90
mmHg), and evidence of
peripheral vasoconstriction
http://en.wikipedia.org/wiki/Killip_class

Mortality Rate
(%)
6
17

30 - 40
60 80

Thank You