Stemi (ST-elevaTION

myocardial infarCT)

DIAN WAHYUNI
(C111 09 348)

Supervisor :
Prof. Dr. dr. ALI ASPAR M, SpPD. SpJP(K), FIHA, FAsCC, FINASIM, FICA

CAS E PRE S E NTAT I ON
Department of Cardiology and Vascular Medicine
Medical Faculty of Hasanuddin University
Makassar
2014
Patient Identity
Name : Mr. M
Age : 72 years old
Gender : Male
Address : jl. Emisaelan 3 no.22
MR : 653885
Day of Admission : March 06 2014

Chief Complaint : Chest Pain
It was felt since 20 hours ago before admit to the hospital.
The pain was felt > 30 minute and the discomfort radiated to
the shoulder, down the left arm and to the back. The pain
didnt infleunce by activity. Cold sweat (+), palpitation (+),
headache (-) Cough (-) dyspneu (+) Nausea (-), vomiting (-),
epigastric pain (-), defecation not yet since the onset of chest
pain, normal urination. DOE (-), PND (-), orthopneu (-), DM (-),
HT (-).
HISTORY TAKING
Past Medical History
History of chest pain (-)
History of heart disease (-)
History of DM (-)
History of smoking (+)
1box/3day since 20 years ago.
History of hypertension (-)
Family History
History of heart disease in
family (-)
RISK FACTORS
Modifiedd

Non- Modified

Gender : Male
Age 72 years
old
History of smoking
Low HDL < 40
General Status
Moderate illness/ Well nourished/ Conscious
Nutritional Status: normal
Weight : 68 kg
Height : 170 cm
BMI : 23.5 kg/m
2



Vital Sign
Blood Pressure : 130/80 mmHg
Pulse Rate : 68 bpm
Respiratory Rate : 24 bpm
Temperature : 36.5
0
C (axilla)


PHYSICAL EXAMINATION
Eye : Conjunctiva anemic (-/-),Sclera icteric
(-/-)
Lip : Cyanosis (-)
Neck : JVP R+0 cmH
2
0
Head and
Neck
Examination
Inspection : Symmetric between left and right chest.
Palpation : No mass, no tenderness.
Percussion : Sonor between left and right chest,
lung-liver border in ICS IV right anterior.
Auscultation: Respiratory sound: Vesicular
Additional sound : Ronchi -/-, Wheezing -/-
Thorax
Examination
Heart examination :
Inspection : apex invisible
Palpation : apex impalpable
Percussion : upper heart : ICS II parasternalis linea
sinistra
bottom heart : ICS IV parasternalis linea dextra
left Heart : ICS IV midclavicularis linea sinistra
right heart : ICS IV parasternalis linea dextra
Auscultation : heart sound I/II regular, murmur (-), gallop
(-)

Inspection : flat, following breath movement
Auscultation : peristaltic (+) normal
Palpation : mass (-), pain (-), liver and lien
impalpable
Percussion : tymphani (+), ascites (-)
Abdomen
examination
Pretibial oedema -/-
Extremities
examination
Electrocardiogram (ECG)
7/3/2014
ECG interpretation
Rhythm : Sinus rhythm
Heart rate : 75 bpm
Regularity : reguler
Axis : Normoaxis -25 degree
P wave : 0,08 s
PR interval : 0,16 s
Q pathologist : -
QRS complex : Duration 0,06 s
ST Segment : ST elevation lead v1, v2 and v3
T inverted : -
Conclution : SR, HR 75 x/minute, normoaxis, acute
anteroseptal myocardial infarction

Radiology findings
Cardiomegaly with
dilatiatio et elongatio
aortae.
Diaphragm elavation
dextra (intrahepatic
process ?? )
LABORATORIUM
HEMATOLOGY RESULT NORMAL
VALUE
UNIT
WBC 7.7 4,00-10,0 (10/UI)
RBC 4,421 4,00-6,00 (10
6
/UI)
HGB 12.41 12,0-16,0 (gr/dL)
HCT 37.8 37,0-48,0 (%)
PLT 192 150-400 (10
3
/uL)
GDS
133
140 Mg/dL
Uric acid
6.0
3,4-7.0 Mg/Dl
Creatinin 1,2 <1,3 Mg/dL
6-7/3/2014
Na 132 136-145 mmol/L
SGOT 39 <38 mmol/L
SGPT 26 <41 Mg/dL
PT
11.4
10-14 detik
APTT 23.2 22-30 detik
CK 157 L<190,P<187 u/L
CKMB 23.3 <25 u/L
TROPONIN T 2.0 <0.05
HDL 21 >55
LDL 118 <130
Working DIAGNOSIS
STEMI ANTEROSEPTAL ONSET > 24
hour KILLIP I
MANAGEMENT
Bed rest
Oxygen 4 lpm via
nasal canule
IVFD NaCl 0.9% 500
cc/24 hr
Nitrat
Cedocard 2 mg/hr/SP
Antiplatelet
Clopidogrel 300 mg
loading dose -> 1 X 75
mg
Aspilet 160 mg loading
dose -> 1 x 80 mg


Anticoagulant
Arixtra 2,5 mg/24 hr/SC
3-8 day
Laxative
Laxadyne syr 0-0-II cth
Statin
Simvastatin 1x20 mg
Anti-anxiety
Alprazolam 0,5 mg 0-0-1
ACE-Inhibitor
Captopril 2x6,25 mg

DISCUSSION
STEMI (ST-ELEVATION
MYOCARDIAL INFARCT)

Imbalance in oxygen supply and demand,
which is most often caused by plaque
rupture with thrombus formation in a
coronary vessel, resulting in an acute
reduction of blood supply to a portion of
the myocardium.
DEFINITION
Is an irreversible necrosis of heart muscle
due to prolonged ischemia, which is
suddenly happened.
RISK FACTORS
Modifiable Non Modifiable
oSmoking
oHypertension
oObesity
oDiabetes Mellitus
oDyslipidemia
-Low HDL < 40
-Elevated LDL/ TG

oGender and age:
-male after age 45 y.o
-female after age 55
y.o
oFamily History
in first degree
relative > 55 y.o for Male
/ 65 y.o for female
WHO Diagnostic Criteria
1. Clinical history of ischaemic type chest
pain
2. Changes in serial ECG tracings
3. Rise of serum cardiac biomarkers such as
creatinine kinase-MB fraction and
troponin-T

Clinical Features
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
conditions favor thrombogenesis
Histological studies indicate that the coronary plaques
prone to rupture are those with a rich lipid core and a
thin fibrous cap.




MANAGEMENT
Treating Chest Pain and Stress:
O2 2-4 LPM
Isosorbid dinitrate 5 mg SL
Low dose aspirin (Aspilet) 80 mg loading 2 tab
160mg
Clopidogrel 75 mg, loading 4 tab 300 mg
Diazepam 2-5 mg / 8 hours

Hemodinamic Stabilization
Fasting first 8 hours after attack, soft food
Laxadyn
Bed rest until 24 hours free from angina
Cardioselective Beta Blocker Bisoprolol
(do not use if hypotension or Bradicardia)
Ace Inhibitor

Myocardial Reperfusion
Thrombolytic effective with onset < 12 hours
Streptokinase (streptase) 1,5 million unit soluted in 100 ml Nacl O,9%
Anti coagulant low molecular weight heparin
Fondaparinux (Arixtra)
Plaque Stabilization Simvastatin


TIMI risk score for STEMI for predicting 30-day mortality.
Morrow D A et al. Circulation. 2000;102:2031-2037
Copyright American Heart Association, Inc. All rights reserved.
KILLIP Classification
Class Definition Mortality %
I No sign of Heart Failure 6
II + S3 and/or ronchi and
elevated of Jugular
venous pressure
17
III Pulmonary Oedema 30-40
IV Cardiogenic shock 60-80
THANK YOU