CASE REPORT

STEMI EXTENSIVE
ANTERIOR KILLIP I
Presented by :
Herin Arini Natalia

Supervisor :
Dr.dr.Idar
Mappangara,Sp.PD,Sp.JP.FIHA.FINASIM

PATIENT IDENTITY
MR number
: 632700
Name
: Mrs. S
Age
: 56 years
old
Date administered : October
15th 2013

History Taking
Chief complaint: Chest pain

It was felt 3 hours ago before admitted to hospital

The pain was felt like pressed by a heavy thing,

penetrated to her back, and radiated into shoulder and
left arm.

Duration of chest pain is more than 30 minutes and

didnt relieved by rest.

Patient feel shortness of breath, sweating, weakness,

and nausea.

Cough (-), shortness of breath history (-),

PND (-), DOE (-) , Ortopneu (-)

History of Past Illness

History of hypertension ( + )

History of diabetes mellitus (+) since 1

years ago with uncontrolled therapy

History of family with CVD ( - )

History of smoking (-)

Risk Factors
Modifiable

Physical Examination
General status
Moderate illness/well
nourished/conscious
Vital sign
BP: 140 / 80 mmHg
HR : 68 x/min
RR : 28 x/min
T
: 36.80 C

Regional Status

Head Examination
o
o
o

Eyes: anemia (-), icterus (-)

Lip
: cyanosis (-)
Neck : lymphadenopathy (-), JVP R - 2 cmH2O

Thoracal Examination
o
o
o
o

Inspection : symetric, normochest

Palpation : mass (-), tenderness (-), VF R=L
Percussion : sonor
Auscultation : breath sound : bronchovesicular

additional sound : ronchi -/-,

wheezing -/-

Regional Status

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

Abdominal Examination
o
o
o
o

Inspection : flat and following breath movement

Auscultation : peristaltic sound (+) , normal
Palpation : liver and spleen unpalpable
Percussion : tympani, ascites (-)

Extremities
o

Oedema

: pretibial (-), dorsum pedis (-)

Electrocardiography
(ECG)

Interpretation

Rhythm : Sinus
Heart rate : 60 bpm
Regularity : reguler
Axis : Normoaxis, 45
P wave : 0,08 s
PR interval
: 0,16 s
QRS wave
: Q patologis V1-V3, durasi
0,08 s
ST Segment : ST elevation Lead I, AVL, V2-V5
T wave : T inverted V1
Conclusion : STEMI extensive anterior

Blood chemistry

Laboratory Examination
Random blood sugar: 329
mg/dl
Complete blood
WBC
: 11.5 x 103 /mm3
()
HGB
: 12.3 g/dl
HCT
: 36. 3 %
RBC
: 4.09 x 106 /mm3
PLT
: 169 x 103 /mm3
Cardiac enzyme
CK
: 131
CK MB : 24 u/L
Troponin T: < 0.02
Electrolyte
Sodium
:137 mmol/l
Potassium
: 3.78 mmol/l
Chloride : 106 mmol/l

SGOT

: 33 u/l

SGPT

: 42 u/l

Ureum : 26
Creatinin : 0.6
PT

: 8.8

APTT

: 19.9

Total Cholesterol : 193

mg/dl
HDL

: 35 mg/dl

LDL

: 122 mg/dl

Triglyseride
Uric acid

: 177 mg/dl

: 3.5

WORKING DIAGNOSIS
STEMI Extensive Anterior
onset 3 jam, KILLIP I

Management

Bed rest

O2 4 LPM (via nasal canule)

Nitrat

Cedocard 2 mg/jam/SP

ASA (Aspilet) loading

dose160 mg ,
maintenance 1x80 mg
Clopidogrel (Plavix)
loading dose 300 mg ,
maintenance 1x75 mg

Trombolytic

Streptase 1,5 million unit

in 100 cc NaCl 0,9% in 1

HMG-Co A reductase
inhibitor (Simvastatin 1 x
20 mg)

Anxiolytic

2 mg/iv

Anti cholesterol

Captopril 3x6,25 mg

Morfin

Anti Platelet Aggregation

ACE-inhibitor

IVFD RL loading 500 cc/24

hours

Benzodiazepin
(Alprazolam) 0,5 mg - 0
-1

Laxative

Laxadin syrup 1 x 2 cth

DISCUSSION
ACUTE CORONARY
SYNDROME
(ST SEGMENT Elevation
Myocardial Infarction)

ANATOMY

PATHOPHYSIOLOGY
STEMI generally occurs when
coronary blood flow decreases
abruptly after a thrombotic
occlusion of a coronary artery
previously affected by
atherosclerosis.
In most cases, infarction occurs
when an atherosclerotic plaque
fissures, ruptures, or ulcerates
and when condition favor
thrombogenesis.

DIAGNOSIS OF CHEST PAIN

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

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

RISK
FACTOR

CLINICAL MANIFESTATION

WHO Diagnostic
Criteria
1.

2.
3.

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

PAIN PATTERNS WITH MI

ELECTROCARDIOGRAM

SERUM CARDIAC
BIOMARKERS
CK-MB

MARKERS
AFTER ACUTE MYOCARDIAL
INFARCTION (AMI).

MANAGEMENT
Fixing the chest pain and fearness
o Bed rest
o Diet
o O2 2-4 lpm via nasal prongs or face mask
o Sublingual/oral/IV nitroglycerine
o Antiplatelet: aspirin and clopidogrel
o Morfin/petidine
o Diazepam 2-5mg/8 hour
Stabilizing the hemodynamic (blood pressure and peripheral
pulse control)
o -blocker if theres no contraindication
o Calcium channel blocker (CCB)
o ACE-Inhibitor
Reperfusion of the myocard
o Thrombolytict

Class
I
II
III
IV

Mortality Rate
(%)

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

6
17
30 - 40
60 80

KILLIP CLASSIFICATION

PROGNOSIS

PREVENTION