Myocardial

Infarction
with
ST segment
PresentedElevation
by :
Aqilah Salha Bt Ahmad Kasmiri
Supervisor :
dr. Pendrik Tandean,SpPD

PATIENT IDENTITY
Name
No.MR
Age
Gender
Date of admitted

: Mr. H.S
: 436760
: 51 years old
: Male
: 27th July 2010

HISTORY TAKING
Chief complaint: Shortness of breath
History taking:
Felt for the last 2days, which happen in a sudden
especially when patient walked 10m after he woke
up in the morning. Its not influenced by weather. He
always sleep using 2-3 pillow. At night, he usually
woke up due to shortness of breath. Chest pain (+),
felt weighted on his left chest for 5 minutes, pain
penetrates to the back of the body and shoulder.
The pain did not improved by rest or medication.
Sweating (+) , Dyspnea (+), Nausea (-)Vomiting (-),
Epigastric pain(-)Cough(-),Defecation & urination is
normal

PAST ILLNESS HISTORY

Hypertension (+) since 3 years ago,

controlled regularly at polyclinic.

Smoking (+) since 30years ago, about 1-

2 box of cigarette per day.

Family history of heart disease (-)

Diabetes mellitus (-)

RISK FACTOR
Gender
Age

: Male
: 51 years old
Heavy smoker, he had smoked 1-2 box of
cigarettes per day for 30 years.
Hypertension (+) since 3 years ago
Dyslipidemia (+)
Past history of cardiovascular disease(-)
Diabetes Mellitus (-)

PHYSICAL EXAMINATIONS
General Appearance :Mild-illness /normal BW /conscious
Vital Sign :
Blood Pressure
Pulse
Respiratory rate
Temperature

: 160/100 mmHg
: 88 bpm, regular
: 28 tpm ; thoracoabdominal
: 36,8 C (per axilla)

Head Examination :
Eyes : anemia(-), icterus(-), cyanosis(-)
Neck : JVP R+2 cmH20
Thoracic Examination :
Inspection
: Symmetric left and right
Palpation
: No mass, no tenderness
Percussion
: Sonor
Auscultation : Breath Sound : vesicular, Rh -/-, wh +/+

 Cardiac Examination :
Inspection
: Ictus Cordis not visible
Palpation
: Ictus Cordis not palpable
Percussion
: Normal heart size increase
Auscultation
: Regular of I/II Heart Sound, murmur (-)
Abdominal Examination :
Inspection
: Flat and following breath movement
Palpation
: Liver and spleen unpalpable
Percussion
: Tympani
Auscultation
: Peristaltic sound (+) , normal effect
Extremities :
Oedema pretibial -/-, feel warm +/+

CHEST X-TRAY
Conclusion:
Cardiomegaly, dilatation et elongation aortae.
Alveolar Edema

ECG INTERPRETATION
Conclusion:
1.Sinus tachycardia (HR: 100x/min)
2.Left axis deviation
3.Right Atrial Enlargement
4.Left Ventricle Hipertrophy
5.Anterior wall Myocardial Infarction

LABORATORY
FINDINGS

ECHOCARDIOGRAPHY
Conclusion:

Global systolic function + LV segmental decrease.

EF 16-42%
Heavy anterior hypo kinetic, hypo kinetic other segment.
LV dilation
RV function is good
MR mild
AR trivial-mild- thrombus (+) at LV
Diastolic function is good

D/ CAD

WORKING DIAGNOSIS
STEMI anterolateral
TIMI 7/16, KILLIP III
Hypertension Grade

II

Dyslipidemia on

treatment

TREATMENT
Total bed rest
O2 2-4 L/min
IVFD NaCl 0.9% 16 drips/min
Anti-platelet aggregation: Aspilet
80mg (0-1-0)
Clopidogrel 75mg
(1-0-0)
Venodilation:Farsorbid 5mg ,
sublingual
:Farsorbid 10mg (1-1-1)
Anti-trombotic: Lovenox
0.6cc/12hrs/IV
ACE Inhibitor:Captopril 25mg (1/2-0-

Acute Myocardial
Infarction

DEFINITION
Myocardial infarction (MI) is rapid

development
of
myocardial
necrosis caused by a critical
imbalance between the oxygen
supply
and
demand
of
the
myocardium.
It results from plaque rupture with

thrombus formation in a coronary

vessels, resulting in an acute

PATHOPHYSIOLOGY
Occurs when coronary blood

flow decreases abruptly after

a thrombotic occlusion of a
coronary artery previously
affected by atherosclerosis.
In

most
occurs

cases, infarction
when
an

RISK FACTORS
Age > 45 years old
Male gender
Smoking
Poorly controlled

hypertension
Hypercholesterolemia /
dyslipidemia
Diabetes mellitus

CLINICAL FEATURES
Chest pain >30 minutes
Feels tight, crushing, and

band like
Location in substernal area
Radiate to left arm, throat,
and jaw
Associated features
including palpitation,
sweating, breathlessness,

TIMI Prognosis in
STEMI
Risk Factor

Score

Age > 65 years old

Age > 75 years old

History of
1/1/1
angina/hipertension/
DM
Systolic BP <100

Heart rate > 100

Killip II-IV

Weight > 67kg

Anterior MI or LBBB

Risk
of Death in
RISK30
FACTORS
days

Total
Score
0
1
2
3
4
5
6
7
8
9-16

0.8%
1.6%
2.2%
4.4%
7.3%
12.4%
16.1%
23.4%
26.8%
35.9%

WHO Diagnostic
criteria
1. Clinical history of

ischaemic type chest

pain lasting >20
minutes
2. Changes in serial ECG
tracings
3. Rise and fall of serum

Diagnose
Signs of myocardial ischemia
ECG
ST segmen elevation ?

Yes

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

No Lab
Biochemical cardiac markers ?

No

Yes

NSTEMI
( No ST-Segment
Elevation
Myocardial
Infarction )
Unstable Angina

ECG

12-lead electrocardiogram showing STsegment elevation (orange) in I, aVL and V1V5 with reciprocal changes (blue) in the
inferior leads, indicative of an anterior wall
myocardial infarction.

MANAGEMENT

COMPLICATION of MI
Based on KILLIP classification:
Classification

Description

KILLIP I

No crackles, no 3rd heart sound

KILLIP II

Crackles in <50% of the lung

field, or a 3rd heart sound

KILLIP III

Crackles in > 50% of lung field,

lung edema

KILLIP IV

Cardiogenic shock

THANK YOU