STEMI

(ST ELEVATION MYOCARDIAL

INFARCTION)
By:
YUNITA
C111 12 168
Supervisor :
dr. Pendrik Tandean, SpPD-KKV, FINASIM

DEPARTMENT OF CARDIOLOGY AND VASCULAR MEDICINE

MEDICAL FACULTY OF HASANUDDIN UNIVERSITY
MAKASSAR
2016
 PATIENT IDENTITY
 Name : Ms. PA
 Age : 47 years old
 Occupation : private employees
 Address : Sultan Hasanuddin Street, Makassar
 MR : 781791
 Date of Admission : December 7th 2016
 HISTORY TAKING
 Chief complaint : Chest pain
 Present Illness History :
 chest pain felt since 6 hours ago before admission
 Described as sharp pain that felt thru to the back,
intermittently, persisted on resting, duration of pain : 10-15
minutes.
 Cold sweating since the night before
 There is history of smoking, no dyspnea, no fever, no nausea
and and no vomiting
 HISTORY TAKING

Past history:
 History of hypertension disease is none
 History of Diabetes disease is none
HISTORY TAKING
 Personal Life History :
 There is history of smoking
 No history of alcohol consumption
 No history of heart disease in the family
 No history of diabetes in the family
 Past Treatment History :
 There is history of hospital admission of liver disease in
the hospital palopo
Physical Examination
 General state:
 Moderate Illness/ Well nourished/Conscious
 Body Weight : 70 kg
 Body Height : 165 cm
 Body Mass Index : 25,7 kg/m2

 Vital state
 Blood Pressure : 100/60 mmHg
 Heart Rate : 61 x/mnt
 Respiratory Rate : 24 x/mnt
 Body Temperature: 36,4 °C
Physical Examination
 Eye :Anemis (-), Icteric (-) ,
 Pupil :Equal, round, diameter 2,5 mm, reactive to light
 Neck :JVP R+1 CmH2O, no lymphadenopathy, no
thyroid enlargement
 Physical Examination
 Chest Examination
 Inspection : Symmetry left = right
 Palpation : Mass (-), tenderness (-),
 Percussion :Sonor left=right;
Lung-liver border in ICS VI anterior
 Auscultation : Breath sound : vesicular
Additional sound : ronchi -/- ; wheezing -/-
PHYSICAL EXAMINATION
 Cor :
 Inspection : ictus cordis visible
 Palpation : ictus cordis palpable, thrill (-)
 Percussion :
 Upper border 2nd ICS sinistra
 Right border 4th ICS linea parasternalis dextra
 Left border 5th ICS linea axillaris anterior sinistra
 Auscultation : heart sound I/II pure, regular,
murmur (-)
Physical Examination
 Abdominal Examination
 Inspection : Convex, following breath movement
 Auscultation : Peristaltic sound (+), normal
 Palpation : Mass (-), tenderness (-), no palpable
liver and spleen
 Percussion : Timpani (+), Ascites (-)

 Extremities examination
 Pretibial edema -/-
 Dorsum pedis edema -/-
 ELECTROCARDIOGRAPHY
Sinus rhytm
HR : 82 bpm
Regularity: iregular
Axis : normoaxis
PR interval : 0.12 s
Q rate : V1-V4
QRS complex : 0,08s
ST segmen :
ST segmen elevation
on lead V1-V4

Conclusion :
Sinus rhytm, HR : 82
bpm, ireguler,
normoaxis, ST elevasi
myocardial infarction,
anteroseptal
LABORATORY RESULTS
TEST RESULT NORMAL TEST RESULT NORMAL

VALUE VALUE

WBC 14,4 x 103/uL 4.0 – 10.0 x 103 Tot.Choles 190 200

HDL 25 >59
RBC 5,01 4.0 – 6.0 x 106
LDL 142 130

HGB 14,1 12 – 16
Trigliserida 160 200

HCT 44,6 37 – 48 Ureum 23 10-50

PLT 333x 103/uL 150 – 400 x 103 Kreatinin 1,25 0,5-1,2

Troponin I 3,88 <0,01

PT 10,2 10 - 14
CK 1878,00 <190
APTT 23,1 22,0 - 30,0
0,91 CKMB 147,3 <25
INR
GDS 198mg/dl 140 Natrium 146 136 - 145

GD2PP - <200 Kalium 3,4 3,5 - 5,1

Klorida 105 97 - 111

SGOT 114u/L <38
Asam Urat - 3,4-7,0
SGPT 35 u/L <41
DIAGNOSIS
 STEMI anteroseptal onset <12 hours,
KILLIP I post primary PCI
TREATMENT
 NaCl 0,9% 500 cc/24 hours/IV
 Aspilet 80mg/24 hours/oral
 Brilinta 90mg/12jam/oral
 Farsorbid 1mg/jam/syringepump
 Arixtra 2,5mg/24jam/subkutan
 Acetylcysteine 400mg/12hours/oral
 Bisoprolol 1,25mg/24jam/oral
 Captopril 0,25mg/8jam/oral
 Laxadyn syr 10cc/24jam/oral
 Alprazolam 0,5mg/24jam/oral
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).
INTRODUCTION
Pathophysiology
RISK FACTORS

Modifiable Non-Modifiable
Smoking Gender & Age
Hypertension • Men > 45 years old
• Women > 55 years old
Diabetes mellitus
Hypercholesterolemia Family history
Obesity • Heart disease in biological
brother or father > 55 years
Psychosocial stress old
• Heart disease in biological
Lack of physical activity sister or mother > 65 years old
 DIAGNOSIS OF ACS

At least 2 of the following

 Ischemic symptoms

 Diagnostic ECG changes  Troponin T

 CK-MB
 Serum cardiac marker
 CK
elevations
 Myoglobin
ISCHEMIC SYPMTOMS
Prolonged pain (usually >20 mins) – may also be described as a dull pain,
constricting, crushing, squeezing
 Usually retrosternal location, radiating to left chest, left arm; can be
epigastric
 Not fully relieved by rest or nitroglicerine
 Dyspnea
 Diaphoresis
 Palpitations
 Nausea/vomiting
 Light headedness
 Sense of “impending doom”
 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 Biomarker
Biochemical marker for detection of myocardial necrosis

First rise after Peak after AMI Return to

AMI normal
CK-MB 4h 24 h 72 h
Myoglobin 2h 6-8 h 24 h
TroponinT 4h 24 - 48 h 5 – 21 d
Troponin I 3-4 h 24 – 36 h 5 – 14 d
GOAL OF TREATMENT
Initial Treatment
 Bed rest
 Oxygen (2-4 lpm)
 Anti platelet therapy :
 Aspirin 160-320mg chewed immediately and 80-160 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%.
 Morphine 2-5mg iv (can be administered again in 5-30 minutes later)
 Fibrinolytic therapy:
 Streptokinase 1.5 million units in 100 mL dextrose 5% or NaCl 0,9% finished in 30 – 60 minutes
 Actilyse : 15 mg bolus iv
0.75mg/kg weight body in 30 minutes
and 0,5 mg/kg weight body in 60 minutes
 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
PROGNOSIS
KILLIP CLASSIFICATION
MORTALITY RATE
CLASS DESCRIPTION
(%)

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 60 – 80
evidence of peripheral vasoconstriction