CASE PRESENTATION:

ST ELEVATION MIOCARD INFARK whole

anterior onset > 18 hours killip 1

PRESENTED BY:
NUR SYAHIRAH BT CHE KAMARUDDIN , C111 12 874
SUPERVISOR PEMBIMBING:
DR. ABDUL HAKIM ALKATIRI ,SP,JP FIHA
 Patient identity

Name : Sir Ln.

Sex : men
Age : 55 years old
Address : Jl. Cilalla Jaya No. 50
Occupation : farmer
Status : married
Enter RS Wahidin : 9 Oktober 2016
File num : 357404
Room : CVCU RSWS
 Chief Complain

chest pain
 Present illness history

Suffered since 3 days ago before admitted to RS Sidrap and then transfer to RS
Wahidin.
This pain was suddenly
Described the pain as been slices by a knife, through to the back and the pain
running from neck to the right arm , pain accompanied with cold sweating and
nausea but not vomit.
He also sometimes feel short of breath after doing some activity or before doing
some activity. Sometimes he feels short of breath when the chest pain come attack.
No epigastric pain
No DOE, PND and orthopnea
History of smoking since young ago with 10-12 cigarettes per day
 History of Past Illness

History hospitalized with Coronary Artery Disease post ( PCI) on Mei 2010
History hospizalized at RS Wahidin because shortness of breath
History of diabetes and treated not regularly
History of hypertension and treated not regularly
No history of heart disease in the family
 PHYSICAL EXAMINATION

Moderate illness/well-nourished/conscious
General condition
(GCS 15: E4M6V5)

BP : 140/100 mmHg
HR : 86 x/minutes
Vital Signs
RR : 25 x/minutes
T : 37,2 oC

Head Anemis (-) , icterus (-)

Neck JVP R + 1 cmH20, lymphadenopathy (-)

 I : symmetric R=L, normochest
Chest P : mass (-), tenderness (-), VF R=L
P : sonor
Examinatio A : breath sound : vesicular additional
n sound : ronchi minimal (+,+) at base of
lung , wheezing (-/-)

I : ictus cordis not visible

P : ictus cordis not palpable
P : dull, Upper border 2nd ICS sinistra, Right
Cor border 4th ICS linea parasternalis dextra, Left
border 5th ICS linea axillaris anterior sinistra
A : HS I/II pure, regular, murmur(-)
Abdomen :
Inspection : flat and correspond with breathing movement
Auscultation : peristaltic sound (+) , normal
Palpation : liver and spleen impalpable, epigastric pain (-)
Percussion : tympani, ascites (-)

Extremities:
Edema -/-
 LABORATORIUM (9-10-2016)

HB increase
RBC slighty increase
Creatinin slighty increase
GDS increase (hiperglikemia)
Uric Acid increase
HDL decrease
 PEMERIKSAAN HASIL NORMAL
WBC 10,84 x 103/mm3 4.0-10.0 x 103
RBC 7,38 x 106/mm3 4.0-6.0 x 106
HGB 20,2 gr/dL 12-16
HCT 63,7 % 37-48
PLT 226 x 103/mm3 150-400 x 103
Ureum 39 10-50 mg/dl
Creatinin 1,53 0.5-1.2 mg/dl
SGOT 29 <35 U/L
SGPT 23 <45 U/L
Na 146 136-145 mmol/l
K 4,2 3.5-5.1 mmol/l
Cl 99 97-111 mmol/l
GDS 330 200 mg/dl
CK 92.000 L(<190U/L) P(<167U/L)
CK-MB 20,7 <25U/L
Troponin T <0,1 <0,05
Kolesterol total 108 200 mg/dl
Uric acid 9,3 L 3,4-7,0 ; P 2,4-5,7
HDL 18 L>55; P>65
LDL 69 <130 mg/dl
Trigliserida 158 200 mg/dl
ELECTROCARDIOGRAPHY (09-10-2016)

Sinus : rhytm, reguler

HR : 75 beat per minutes
Axis : Superior axis deviation (extreme)
PR-Interval : Normal
P-Wave : Normal
QRS Duration : 0,08 minute
ST-segment : elevation on V1-V5

Conclusion
Sinus rhytm, superior axis deviation (extreme) ,
whole anterior miokard infark .
 CHEST X-RAY

Bronkovascular within normal limits

Does not have any specific process at both lungs
Heart: enlarged impression with thoracal index : 0,71
Aortae dilatation and classification
Both sinus and diaphragm are good in condition
The bones intact

Impression:
Cardiomegaly with dilatatio et atherosclerosis aortae
 Risk Faktor
Modified Risk Factor
Diabetes Mellitus
Smoking (1 pack per day )
Hipertension
Work as a farmer
Non-modified risk factor:

Gender : male
55 years old
 RESUME
A male patient age 55 years old came to the hospital complained about chest pain
that he suffered since 3 days ago before admitted to RS Sidrap and then transfer
to RS Wahidin. The pain was suddenly occur and he described the pain as been
slices by a knife, through to the back and the pain running from neck to the right
arm , pain accompanied with cold sweating and nausea but not vomit. He also
sometimes feel short of breath after doing some activity or before doing some
activity. Sometimes he feels short of breath when the chest pain come attack. He
has not experienced epigastric pain, DOE, PND or orthopnea. Patient has history
of smoking since young ago with 10-12 cigarettes per day. He has been
hospitalized with Coronary Artery Disease post PCI on Mei 2010. He has
hipertension and diabetis melitus but not consumed the meds regularly. From
chest examination has found there are ronkhi sound at the basal of the lung and
the conclusion of the electrocardiography test are Sinus rhytm, superior axis
deviation (extreme) , whole anterior miokard infark .
 Diagnosis

ST ELEVATION MIOCARD INFARK

whole anterior onset > 18 hours killip 1
Congestive Heart Failure NHYA III
Coronary Artery Disease post PCI
Diabetes Mellitus type 2
Hipertensi
 Treatment
O2 2-4 liter per minutes via nasal kanul
IVFD NaCl 0.9% 500 ml/24 hours
Isosorbide dinitrate: Farsorbid 10 mg / 8 hours / oral
Captopril 12.5 mg / 8 hours / oral
Beta Blocker: Bisoprolol 1:25 mg / 24 h / oral
Laxadyn syrp 10 cc / 24 hours / oral
Benzodiazepines: Alprazolam 0.5mg / 24hr / oral
Statins's group: Atorvastatin 40mg / 24hr / oral
Diuretics: Furosemide 40mg / 12 hours / oral
Anti Platelet Aggregation:
Aspilet (loading dose 325 mg) maintenance 1x80 mg
Clopidogrel (loading 600 mg) maintenance 1x75 mg
 PLANNING

Echocardiography
Angiography
How to make the
diagnosis?
 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).
Myocardial infarction (MI) rapid development of myocardial necrosis caused
by a critical imbalance between the oxygen supply and demand of the myocardium.
This usually results from plaque rupture with thrombus formation in a coronary
vessels, resulting in an acute reduction of blood supply to a portion of the
myocardium.
 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.
 Diagnosis Of Acute Coronary Syndrome (ACS)

At least 2 of the following (WHO criteria):

Ischemic symptoms

Diagnostic ECG changes

Serum cardiac marker elevations

 Diagnosis Of Acute Coronary Syndrome (ACS)
Prolonged chest pain
At least 2 of the following
(usually >20 minutes)
constricting, crushing,
Ischemic symptoms
squeezing

Diagnostic ECG changes Usually retrosternal

location, radiating to
Serum cardiac marker left chest, left arm; can
be epigastric

elevations Dyspnea
Diaphoresis
Palpitations
Diagnosis Of Acute Coronary Syndrome (ACS)

At least 2 of the following

Ischemic symptoms

Diagnostic ECG changes

Serum cardiac marker

elevations
ECG evolution for Miocardiac Infarct (MI)
 Diagnosis Of Acute Coronary Syndrome (ACS)
At least 2 of the following

Ischemic symptoms Troponin T (N: < 0,05)

Diagnostic ECG changes CK-MB (N: <25 U/L)

CK (N: <190 U/L)

Serum cardiac marker
Myoglobin
elevations
 DIAGNOSIS
Signs of myocardial ischemia

ECG

ST segmen elevation? Yes Acute Myocardial Infarction

( Q-wave, non-Q wave )

No Lab
NSTEMI
Yes (No ST-Segment
Biochemical cardiac markers? Elevation
Myocardial Infarction)

No
Unstable Angina
 Non-occlusive thrombus
Non-specific on ECG
Unstable Normal cardiac enzyme markers
Angina
Occluding thrombus sufficient to cause tissue damage & mild
myocardial necrosis
ST depression +/-
T wave inversion on ECG
NSTEMI Elevated cardiac enzyme markers

Complete thrombus occlusion

ST elevation on ECG
Elevated cardiac enzyme markers
STEMI Symptoms more severe
INFARCT LOCATION
 KILLIP CLASSIFICATION
Class Description Mortality Rate (%)

I no clinical signs of heart failure 6

II rales or crackles in the lungs, an 17

S3, and elevated jugular venous
pressure

III acute pulmonary edema 30 - 40

IV cardiogenic shock or hypotension 60 80
(systolic BP < 90 mmHg), and
evidence of peripheral
vasoconstriction
 GOAL OF TREATMENT

Hemodynamic
Relieve pain
stabilization

Myocardial Prevent the

reperfusion complication
 COMPLICATIONS

Ventricular Hemodynamic
dysfunction disturbances

Cardiogenic
Arrhythmia
shock
Thank you