By:

SUCIATI
SITI ARIFAH
A.YUSRIANA AZZARAH
NURUL INDAH PERTIWI
BESSE JUMRANA
ARMAWATi
SRI MEGAWATI

Supervisor :
DR dr. Idar Mapangara, SpPD, SpJP, FIHA, FICA, FINASIM

DEPARTMENT OF CARDIOLOGY AND VASCULAR MEDICINE

MEDICAL FACULTY OF HASANUDDIN UNIVERSITY
MAKASSAR
2016
 PATIENT IDENTITY
Name : Mr. Y
Age : 65 years old
Occupation : retired
Address : Pondok Asri II Blok E/21
MR : 755130
Date of Admission : April 23th 2016
 HISTORY TAKING
Chief complaint: Chest pain
Present Illness History :
Left chest pain felt since 5 hours before admission
Described as pressed pain which radiates to the back
and right arm. Duration of pain is more than 20
minutes. Pain is associated with cold sweating.
Not fully relieved by rest
There is no dyspnea at onset, no fever, no nausea and no
vomiting
 HISTORY TAKING
Past history:
There is history of hypertension for 5 years, which is
not well controlled
There is no history of chest pain
There is no history of heart disease
There is no history of Diabetes Mellitus
HISTORY TAKING
Personal Life History :
No history of smoking
No history of alcohol consumption
No history of heart disease in the family
No history of diabetes in the family

Past Treatment History :

No history of hospital admission
Physical Examination
General state:
Moderate Illness/ Well nourished/Composmentis
Body Weight : 70 kg
Body Height : 175 cm
Body Mass Index : 22,8 kg/m2

Vital state
Blood Pressure : 130/80 mmHg
Heart Rate : 80 x/mnt
Respiratory Rate: 18x/mnt
Body Temperature: 36,5 C (axilla)
Physical
Head Examination
:Normochepalic
Eye :Anemis (-), Icteric (-)
Pupil :Equal, round, diameter 2,5 mm, reactive
to light
Nares :Appearance is normal
Lip :No cyanosis
Neck :JVP R+2 cmH2O, no lymphadenopathy,
no thyroid enlargement
Physical Examination
Chest Examination
Inspection : Symmetrical left = right
Palpation : Mass (-), tenderness (-),
Percussion :Sonor left=right;
Lung-liver border in ICS VI anterior
Auscultation : Breath sound : vesicular
Additional sound : ronchi -/-
wheezing -/-
PHYSICAL EXAMINATION
Cor :
Inspection : ictus cordis is visible
Palpation : ictus cordis palpable, thrill (-)
Percussion :
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea axillaris anterior
sinistra
Auscultation : heart sound I/II pure, regular,
murmur (-)
Physical Examination
Abdominal Examination
Inspection : Convex, following breath movement
Auscultation : Peristaltic sound (+), normal
Palpation : Mass (-), tenderness (-), no palpable
liver and spleen
Percussion : Timpani (+), Ascites (-)

Extremities examination
Pretibial edema -/-
Dorsum pedis edema -/-
 ELECTROCARDIOGRAPHY
Sinus rhytm
HR : 90 bpm
Regularity: regular
Axis : normoaxis
PR interval : 0.12 s
QRS rate : 0.08 s
QRS complex :
normal
ST segmen :
ST segmen
elevation on lead
II,III,aVF, on lead
V5 ,V6

Conclusion :
Sinus rhytm, HR :
90 bpm, inferior +
lateral walls
myocardial
infarction
LABORATORY RESULTS
TEST RESULT NORMAL TEST RESULT NORMAL

VALUE VALUE

WBC 13.100 x 4.0 10.0 x 103 Total - 200

103/uL Cholesterol
RBC 4,33 4.0 6.0 x 106 HDL - >59

LDL - 130
HGB 12.9 12 16
Triglyceride - 200
HCT 36,2 37 48
295x 103/uL Ureum 17 10-50
PLT 150 400 x 103
Creatinine 0.69 0,5-1,2

PT 9.9 10 - 14 Troponin I 2,48 <0,01

APTT 25.2 22,0 - 30,0 CK 523,00 <190
INR 0.95
CK-MB 53.5 <25
GDS 117mg/dl 140
Natrium 142 136 - 145
GD2PP - <200
Kalium 3,5 3,5 - 5,1

SGOT 60u/L <38 Chloride 111 97 - 111

SGPT 20 u/L <41 Uric Acid - 3,4-7,0
CHEST X-RAY

Result :
Active old
pulmonary
tuberculosis wide
lesion
Left pleural effusion
DIAGNOSIS
ST ELEVATION MYOCARDIAL
INFARCTION INFERIOR + LATERAL 5
HOURS ONSET
TREATMENT
Oxygen 2-4 liters per minute via nasal cannule
IVFD NaCl 0,9% 500 cc/24 hours/IV
Nitrate (Cedocard) 1 mg/jam/syringe pump
Aspirin 160mg (loading dose) 80mg/24
hours/oral (maintenance)
Clopidogrel 300mg (loading dose) 75 mg/24
hours/oral (maintenance)
Actilyse (Fibrinolytic) :
15 mg bolus iv
50 mg/syringe pump in 30 minutes
35 mg / syringe pump in 60 minutes
Simvastatin 40 mg/24 hours/oral
Captopril 12,5 mg/8 hours/oral
Bisoprolol 2,5 mg/24 hours/oral
DISCUSSION
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).
Introduction
PATHOPHYSIOLOGY

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org
SYMPTOMS
ECG
ST segment elevation 0,1 mV from J point on 2 or
more pair leads.
RELATION BETWEEN INFARCT
LOCATION WITH Q-WAVE AND
ST ELEVATION
Location Coronary Arteries ECG Leads
CARDIAC MARKER
CARDIAC MARKER
Biochemical marker for detection of myocardial
necrosis
First rise Peak after Return to
after AMI AMI normal
CK-MB 4h 24 h 72 h
Myoglobin 2h 6-8 h 24 h
Troponin T 4h 24 - 48 h 5 21 d
Troponin I 3-4 h 24 36 h 5 14 d
ALGORITMA EVALUASI SKA
MANAGEMENT
INITIAL MANAGEMENT
Evaluate ABC
Bed rest
Oxygen (2-4 lpm via nasal cannule)
Anti platelet therapy :
Aspirin 160-320mg chewed immediately and 80-160 mg continued
indefinitely.
Clopidogrel 300-600mg loading dose and 75mg continued daily for at
least 14 days and up to 12 months.
Nitroglycerin :
0.4 mg SL tablets every 3-5 min up to 3 times; if effect is not sustained,
can continue with an IV drip of 50mg in 250mL Dextrose 5%.
Morphine 2-5mg iv (can be administered again in 5-30 minutes later)- if
needed
REPERFUSION THERAPY
Fibrinolytic therapy:
Streptokinase 1.5 million units in 100 mL dextrose 5% or NaCl 0,9%
finished in 30 60 minutes
Actilyse : 15 mg bolus iv
0.75mg/kg weight body in 30 minutes
and 0,5 mg/kg weight body in 60 minutes
Anticoagulation therapy ( for STEMI patient with fibrinolytic therapy, given for
5 days)
Low Molecular Weight Heparins (Enoxaparine) 0.4cc/sc
Unfractionated heparin
Intervention therapy Percutaneous coronary intervention (PCI) atau CABG in
2 hours
LONG TERM THERAPY
1. Control risk factors, such as hypertension, diabetes,
and tobacco consumption.
2. Antiplatelet therapy with low dose aspirin.
3. Beta-blockers
4. Lipid profile control.
5. High dose statins
6. ACE-I/ARB
7. Aldosteron antagonist
COMPLICATION
Hemodynamic disturbance
Heart failure
Arrhythmia
Cardiac complication
Mitral regurgitation
Heart rupture
Ventricular septum rupture
Right ventricle infarct
Pericarditis
Left ventricle aneurysm
Left ventricle thrombus