CASE REPORT, SEPTEMBER 2011

STEMI Extensive Anterior Wall

Presented by: Fransiska C. Subeno (C11107156) Supervisor: dr. Abdul Hakim Alkatiri, Sp.JP, FIHA

PATIENTS IDENTITY

Name : Mr. A Age : 52 years old Register no. : 47 82 46 Date of admission : September, 4th 2011

HISTORY TAKING
Chief complaint : Chest pain
y It has been felt since four hours before admitted

to the hospital. The history of chest pain had been felt since two days ago, lost and appeared, but since 08.30 a.m. on the day he was admitted, it was felt continuously, sometimes he felt like strangulated. Cold sweat (+) everytime he had a chest pain, dyspnea (-), nausea (-), vomitting (-)

y Defecation and urination are normal

History of Past Illness

y History of chest pain (-) y History of hypertension (-) y History of Diabetes Mellitus (-) y History of dyslipidemia (-) y Family history of heart disease (-) y History of smoking (+) about 1-2 packs a

day for about 20 years.

Risk Factors

MODIFIABLE : Hypertension (-) Diabetes mellitus (-) Dyslipidemia (-) Smoking (+) Obesity (-)

NON-MODIFIABLE Gender : man Age : 52 years old Personal history of CAD (-) Family history of CAD (-)

PHYSICAL EXAMINATION
General Status :

moderate-illness/well-nourished/composmentis
Vital Sign :

BP = 130/90 mmHg Pulse = 85 bpm, regular RR = 22 bpm Temperature = afebris

Regional Status
Head Examination  Eyes : anemic -/-, icterus -/ Lip : cyanosis (-)  Neck : lymphadenopathy (-), JVP R-1 cmH2O supine Chest Examination  Inspection : symmetric R=L, normochest  Palpation : mass (-), tenderness (-), VF R=L  Percussion : sonor  Auscultation : vesicular breath sound, no additional sound

Regional Status
Cardiac Examination  Inspection : IC wasnt visible  Palpation : IC wasnt palpable  Percussion : normal heart size
   

Upper border : left 2nd ICS Lower border : left 5th ICS Right border : right parasternalis line Left border : left medioclavicular line

 Auscultation : Regular of I/II heart sound, murmur (-)

Regional Status
Abdominal Examination  Inspection : convecs and following breath movement  Auscultation : peristaltic sound (+) , normal  Palpation : liver and spleen unpalpable  Percussion : tympani, ascites (-) Extremities  Oedema : pretibial -/- ; dorsum pedis -/ Cold extremities (-)

ELECTROCARDIOGRAPHY
(4th September 2011 at emergency unit)

Interpretation
y Sinus Rhythm, heart rate 76 bpm y Left Axis Deviation y Pathological Q wave at V1-V4 y Elevation of ST segment at I, aVL, V1-V5 y Normal T wave

Conclusion: ST elevation myocardial infarction on extensive anterior wall

LABORATORY FINDINGS
Haematological Routine Examination WBC = 12,50. 103 RBC = 4,94. 106 HGB = 16,1 HCT = 46,3 PLT = 290. 103 Chemical Blood Examination and Cardiac enzymes GDS = 108 GOT/GPT = 31/37 CK = 222 CKMB = no reagen Trop-T = 0,13

WORKING DIAGNOSE
y ST Elevation Myocardial Infarction extensive

anterior wall

MANAGEMENT
y O2 4-6 L/minute y IVFD NaCl 0,9% 10 drips per minute y Aspirin (Aspilet) 180 mg (loading dose), then continued y y y y y y y

once daily on the next day Clopidogrel (Plavix) 300 mg (loading dose), then continued once daily on the next day Nitrat (Farsorbid) 5 mg (SL), then continued with Farsorbid via SP Na Fondaparinux (Arixtra) 2,5 mg/24 hours/SC Simvastatin 20 mg 0-0-1 Captopril 12,5 mg three times daily Laxadyn syr. twice daily The patient must be catheterized

PLANNING
y Enter the patient to CVCU y Monitoring ECG everyday y Echocardiography y Coronary Angiography

ECHOCARDIOGRAPHY

Interpretation
y Conclusion:
 Systolic

and dyastolic dysfunction of left ventricle e.c. Coronary Artery Disease  Left Ventricle Hypertrophy  EF 36%

INTRODUCTION
irreversible necrosis of heart muscle due to prolonged ischemia, which is suddenly happened. y Acute myocardial infarction (AMI) is one of the most common diagnoses in hospitalized patients in industrialized countries.
y Acute myocardial infarction (AMI) is an

PATHOPHYSIOLOGY
y STEMI

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

CLINICAL FEATURES
y Deep and visceral chest pain > 20 minutes, similar to

y y

y y

discomfort of angina pectoris but commonly occurs at rest, more severe, and lasts longer. Feels like heavy, squeezing, crushing, burning sensation Involves the central portion of chest and/or the epigastrium, radiates to the arm, abdomen, back, lower jaw, and neck. It is often accompanied by weakness, sweating, nausea, vomiting, anxiety. Not relieve with rest or nitrat

HOW TO DIAGNOSE
Signs of myocardial ischemia ECG
Yes

ST segmen elevation?
No

Acute Myocardial Infarction

Lab
Yes NSTEMI ( Non ST-Elevation Myocardial Infarction )

Biochemical cardiac markers ?

No

Unstable Angina

ADDITIONAL EXAMINATION (1)

y Electrocardiogram  It is begun with depression of ST-segment and inverted of Twave  Then it is changed to elevation of ST-segment and absence of R-wave until the presence of Q-wave

ADDITIONAL EXAMINATION (2)

y Serum cardiac biomarkers  Certain proteins are released from necrotic heart muscle after STEMI  Cardiac Troponin (cTnT and cTnI) are not normally detectable in the blood of healthy individuals but may increase after STEMI to levels >20 times higher than the upper reference limit  Other serum cardiac biomarkers are Creatine phosphokinase (CK) and the MB isoenzyme of CK

MANAGEMENT
y 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 y Stabilizing the hemodynamic (blood pressure and peripheral pulse

control) o -blocker o Calcium channel blocker (CCB) o ACE-Inhibitor y Reperfusion of the myocard o Thrombolytic