ST ELEVATION MYOCARDIAL

INFARCTION

Presented by:
Rezky F Saban (C11110103)
Supervisor:
Dr.dr. Idar Mappangara, Sp.PD,SpJP,FIHA,FINASIM.
CARDIOLOGY DEPARTMENT
MEDICAL FACULTY OF HASANUDDIN UNIVERSITY
MAKASSAR
2015

PATIENT IDENTITY
Name

: Mr. H

Age

: 54 years old

Gender

: Male

Address

: Kutulu

MR

: 698129

Date of Admission : January 22th 2015

HISTORY TAKING
Chief Complaint : Chest Pain
Present Illnes History :
It was felt since 4 hours ago before he was admitted to the hospital.
The pain felt like compress pain by weight thing, continous,not
radiating and along with cold sweating.No dispnea,no dispnea on
exertion,no orthopnea,no paroxysmal nocturnal dispnea, no
cough,no fever,no nausea,no epigastric pain.Defecation and
urination within normal limit.

PREVIOUS ILLNESS HISTORY

No history of diabetes Mellitus
Nohistory of hypertension
No history of previous chest pain
No history of heart disease at the past
No history of heart disease in the family
No history of drinking alcohol
No history of smoking

RISK FACTORS
Modified

Non-modified

Gender : Male
Age: 66 years old

PHYSICAL EXAMINATION
General Status
Moderate illness/ Well nourished/ Compos mentis
Nutritional Status:
Weight : 70 kg
Height : 170 cm
BMI

: 24,22 kg/m2 (overweight)

Vital Sign
Blood Pressure
: 110/60 mmHg
Pulse Rate
: 71 bpm
Respiratory Rate : 22 bpm
Temperature
: 36.5 0C (axilla)

Head and Neck Examination

Eye : Conjunctiva anemic (-/-),
Sclera icteric (-/-)
Lip : Cyanosis (-)
Neck : JVP R+1 cmH20
Thorax 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 VI right anterior.
Auscultation:
Respiratory sound: Vesicular
Additional sound : Ronchi -/- , Wheezing -/-

Heart examination :
Inspection : Apex invisible

Palpation : Apex impalpable

Percussion :
Upper heart : ICS II parasternalis linea sinistra
Bottom heart : ICS V parasternalis linea dextra
Left Heart : ICS V midclavicularis linea sinistra
Right heart : ICS IV parasternalis linea dextra
Auscultation : heart sounds I/II regular, murmur (-), gallop (-)

Abdomen Examination :
Inspection : flat, following breath movement
Auscultation : peristaltic sound (+), normal
Palpation : mass (-), pain (-), liver and lien impalpable
Percussion : tymphani (+), ascites (-)
Extremities Examination :
Oedema Pretibial -/ Oedema dorsum pedis -/-

LABORATORY FINDING
January 22th 2015 (1st day of treatment)

TEST

RESULT

NORMAL VALUE

GDS

160 mg/Dl

<140

SGOT

29 u/L

<38

SGPT

29 u/L

<41

Ureum

35

10-50

Kreatinin

0,90

0,5-1,2

LABORATORY FINDING
January 22th 2015 (1st day of treatment)
TEST

RESULT

NORMAL VALUE

Troponin I

0.12

<0,01

CK

129

<190

CKMB

27.3

<25

Natrium

139

136 - 145

Kalium

4,7

3,5 - 5,1

Klorida

106

97 - 111

Asam Urat

8.8

3,4-7,0

ELECTROCARDIOGRAM

ECG INTERPRETATION
Interpretasi
Ritme

: Sinus Rhytm
Heart Rate
: 83 bpm
Axis
: Normoaxis
P wave
: 0,08s
PR Interval
: 0,20s
QRS complex : 0,10s,
ST Segment : ST Elevation pada lead II, III, aVF
Conclusion
: ST-Elevation Myocardial Infarction
Inferior
Conclusion : Sinus Rythm, HR 83 bpm, ST-Elevation
Myocardial Infarction Inferior

DIAGNOSIS
Inferior STEMI Onset 4 Hours KILLIP I

MANAGEMENT
O2 4 lpm via nasal canule
IVFD NacL 0,9 % 500 cc/24 hours
Actilyse 1 vial/syringe pump (15 mg over in 15 minute,

continue 35 mg over in 45 minute)

Aspilet 80mg/ 24 hours/ oral
Clopidogrel 75mg/ 24 hours/ oral
Atorvastatin 40mg/ 24 hours/ oral
Farsorbid 10mg/ 8 hours/ oral
Arixtra 2.5mg/ 24 hours/ subcutan
Laxadine 10cc / 24 hours/ oral
Alprazolam 0,5 mg/ 24 hours/ oral

DISCUSSION

DEFINITION
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.

CLASSIFICATION

ACS describe a group of conditions resulting from acute myocardial

ischemia (insufficient blood flow to heart muscle) ranging from
unstable angina to myocardial infarction.

Diagnosis of ACS
At least 2 of the following :
1. Ischemic
symptoms
2. Diagnostic ECG
changes
3. Serum cardiac
marker elevations

Difference Between cardiac chest pain and non

cardiac chest pain
The classic presenting complaint of cardiac chest pain is

chest discomfort, which patients often describe as

substernal tightness, heaviness, or pressure.

RISK FACTORS
Non- Modified

Modifiable

Gender and Age

Smoking

Hypertension

Diabetis Mellitus

Dyslipidemia

Obesity

Lack of physical activity

Men, increased risk age > 45 years

old
Women, increased risk age > 55
years old
Family History

Sign and Symptoms of Myocardial Infarction

CHANGES IN ECG

ECG Findings
Site of infarction

Sign of electrically inert

Myocardium

Anteroseptal

V1-V3, sometimes V4

Anterior

V2-V4. Late R progression

in precordial leads.

Anterolateral

V4-V6

Lateral

V5-V6

Extensive Anterior

V1-V6

High Lateral

I, aVL

Inferior

II, III, aVF

Inferolateral

II, III, aVF and V5-V6

Posterior

Initial R in V1, V2. >0.04s.

Cardiac biomarkers

Diagnose
Signs of myocardial ischemia
ECG

Yes
ST segmen elevation ?

No

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

Lab

Biochemical cardiac markers ?

Yes

NSTEMI
(No ST-Segment Elevation
Myocardial Infarction)

No

Unstable Angina

TREATMENT

Prognosis
KILLIP CLASSIFICATION
Clas
s

Description

Mortality Rate
(%)

no clinical signs of heart failure

II

rales or crackles in the lungs, an

S3, and elevated jugular venous
pressure
acute pulmonary edema

17

III
IV

cardiogenic shock or hypotension

(systolic BP < 90 mmHg), and
evidence of peripheral
vasoconstriction

30 - 40
60 80

TIMI PROGNOSIS
Risk Factor

Score

Age > 65 years old

>/= 75

2
3

History of
angina/hipertension/DM

Total
Score

Risk of
Death in 30
days

0.8%

1.6%

2.2%

Systolic BP <100

4.4%

Heart rate >100

7.3%

Killip II-IV

12.4%

Weight >67 kg

16.1%

Anterior MI or LBBB

23.4%

Delay treatment >4 hours

26.8%

9-14

35.9%

THANK YOU