Anteroseptal

ST Elevation Myocardial Infarction

Onset > 12 hours KILLIP 1

Created by:
Wahyunita (C11109132)
Supervisor:
dr. Pendrik Tandean, Sp.PD-KKV,
FINASIM

CARDIOLOGY DEPARTMENT
MEDICAL FACULTY OF HASANUDDIN UNIVERSITY
MAKASSAR 2014

Patient Identity
Name
: Mr. M
Age
: 55 years old
Gender
: Male
Address
: Jl. Rusa BTN Blok F No. 8,
Makassar
Medical Record: 661765
Date of Admission: May 2nd, 2014

History Taking
CHIEF COMPLAINT

Chest Pain

PRESENT ILLNESS HISTORY

Chest pain was felt since 20 hours before admitted to the
hospital. Pain was felt on the left side of chest and radiated
to the shoulder, and his left arm. Pain was felt on the left
suddenly for more than 20 minutes. Chest pains not
influenced by activity and does not disappear with rest.
Cold sweat (+), palpitations (+), shortness of breath (-).

Fever (-), history of fever (-)

Dizziness (-), headache (-)
Cough (-), mucus (-)
Nausea (-), vomiting (-), epygastric pain (-)
Normal urination and defecation

Continue..

Previous Illness History

History of diabetes mellitus (-)
History of hypertension (-)
History of dyslipidemia (-)
History of smoking (+) since 10 years ago.
History of chest pain before (-)
History of heart diseases (-)
Family history with heart disease (-)

Risk Factors
Modifiable Risk
Factor

Diabetes
Mellitus

Non-modifiable
Risk Factor

Female
> 60
years old

Physical Examination
GENERAL
APPEARANCE - Moderate Illness/Well Nourished/

Composmentis

kg/m2

- Body Weight : 60 kg
- Body Height : 160 cm
- Body Mass Index (BMI) :

VITAL SIGN
BP : 100/70 mmHg
HR
: 76 x/min
RR: 20x/min
T
: 36.80 C

22.2

REGIONAL STATE
Head Examination
- Eyes : Anemis -/-, icterus -/- Lip : Cyanosis (-)
- Neck : JVP R +2 cmH2O

Chest Examination
- Inspection
: Symmetric right = left,
normochest
- Palpation
: No mass, no tenderness
- Percussion
: Sonor, lung-liver border in ICS
VI right anterior
- Auscultation : Breath sound : Vesicular
Additional sound : Ronchi -/Wheezing -/-

 Cardiac Examination
- Inspection
- Palpation
- Percussion

: Ictus cordis invisible

: Ictus cordis impalpable
: Right heart border in right parasternal
line, left heart border in left midclavicle
line ICS V
- Auscultation
: Regular of I/II heart sound, no murmur

Abdominal
- Inspection : flat, following breath movement
- Auscultation : Peristaltic sound (+), normal
- Palpation
: No mass, no tenderness, liver and spleen
unpalpable
- Percussion : tymphani, ascites (-)

Extremities
- Oedema pretibial -/- Oedema dorsum pedis -/-

Continue

Chest X-Ray (2/5/2014)

Suprahilar
bronchovascular dilatation
patterns within broad hilar

Normal CTI, aorta

dilatation

No abnormalities on both
sinuses and diaphragm

Intact bones

Result
Signs of pulmonary stank
Aorta dilatation

ECG (2/5/2014)

ECG Interpretation

Rhythm

: Sinus Rhythm

Heart Rate : 75x/ minute

Axis

P Wave

PR Interval

QRS Duration : 0.08 s

ST Segment

T inverted : -

: Normal axis
: 0.08 s
: 0.16 s
: ST Elevation on V1-V4

Result : Sinus Rhythm, Heart Rate 75x/minute, Normal axis, Anteroseptal

miocard infarction

Laboratory Findings (2/5/2014)

Complete Blood Count
Test

Result

Normal value

WBC
RBC
HGB
HCT
PLT

14 x 103/uL
4,11x 106/uL
12,5 g/dL
37,3 %
173x 103 /uL

4.0 10.0 x 103

4.0 6.0 x 106
12 16
37 48
150 400 x 103

Continue

Blood Chemistry
Test
RBG
SGOT
SGPT

Result
111 mg/dL
355 u/L
71 u/L

Normal value
<140
<38
<41

Ureum

18

10-50

Creatinin

0,9

L(<1,3) P(<1,1)

Total Cholesterol

150 mg/dl

200

HDL Cholesterol

34 mg/dl

L (<55) P(<65)

LDL Cholesterol

104 mg/dl

<130

Continue

Cardiac Enzymes
Test

Result

Normal value

Troponin-T

>2

<0,05

CK

4545

L(<190), P(<167)

CK-MB

92

<25

Working Diagnosis
Anteroceptal
ST Elevation Myocardial Infarction
Onset > 12 hours KILLIP I

Therapy

Bed rest
O2 4 lpm via nasal canul
Anti-Platelet: Aspilet 80 mg (loading dose 2x80 mg)
Clopidogrel 75 mg (loading dose 4x75 mg)
Anticoagulant: Lovenox (LMWH) 0,6 cc/12 hours/SC
Nitrat: Cedocard 2 mg/hour/SP
Diuretic: Lasix (Furosemide) 2 amp/8 hours/IV
Statin: Simvastatin 1x 20 mg
Anti-anxietas: Alprazolam 0,5 mg 0-0-1
Laxative: Laxadyn syr 0-0-2 C

Discussion
Acute Coronary Syndrome
(ST Elevation Myocardial Infarction)

Definition
Acute Coronary Syndrome (ACS) is a term for situations
where the blood supplied to the heart muscle is suddenly
blocked.
describe 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).

Classification

Non-Modifiable
Gender and Age

Modifiable
Smoking

Hypertension
Family History
Diabetes Melitus
Dyslipidemia
Obesity

Risk Factors

Diagnosis of ACS
At least 2 of the following :

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

1. Ischemic Symptoms
Duration of chest pain > 20 minutes, at substernal
area
Substernal chest pain / chest discomfort radiated
to the left arm, shoulder, neck, jaw
Not fully relieved by rest or nitroglycerine

The chest discomfort may also be described as a

dull pain ,pressure, squeezing or crushing
sensation or burning sensation
Associated features including palpitation,
sweating, breathlessness, and nausea.

2. Diagnostic ECG Changes

3. Serum Cardiac Marker Elevation

CK

CK-MB
Troponin
T

Diagnosis
Signs of myocardial ischemia
ECG
ST segmen elevation ?

No

Lab

Biochemical cardiac markers ?

Yes

Yes

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

NSTEMI
(No ST-Segment Elevation
Myocardial Infarction)

No

Unstable Angina

Therapy

Bed rest
Diet
O2 2-4 lpm via nasal prongs
Nitrat:
ISDN 10 mg or 20 mg, 2-3 a day.
ISDN 5 mg SL when chest pain.
Antiplatelet:
Aspirin 160-325 mg chewed immediately and 80-160 mg
continued indefinitely.
Clopidogrel 300-600 mg loading dose and 75 mg daily
continued
Trombolitic: (if onset < 6 hours) 1,5 million unit IV in a hour

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

17

III

acute pulmonary edema

30 - 40

IV

cardiogenic shock or hypotension

(systolic BP < 90 mmHg), and
evidence of peripheral
vasoconstriction

60 80

TIMI PROGNOSIS
Risk Factor

Score

Age > 65 years old

>/= 75

2
3

History of
angina/hipertension/DM

Systolic BP <100

Heart rate >100

Killip II-IV

Weight >67 kg

Anterior MI or LBBB

Delay treatment >4 hours

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%

THANK YOU