Jamaluddin, MD, FIHA

Bimo Bintoro, MD, FIHA

Henry S. Sauala, MD
Adhytya Pratama, MD
INTRODUCTION
Case
 A 45 years-old gentleman visiting ED with chief complaint
of chest pain 14 hours prior to admission. The pain
characteristic was consistent to MI.
 The night before, he initially sought no medical attention
and rest at his home. Afterwards in the morning, the pain
was felt again with the scale of 8/10+ dyspnea, and his wife
took him to ED. Risk Factor: Active Smoker, Dyslipidemia.
 PEx:
 110/60 mmHg; 100 bpm; 22x/m; 36,9OC
 Gallop S3 (+), Rales: --+/--+; JVD R+3
ED EKG
 His ECG showed anterior extensive MI, MI algorithm
activated.
 Working Dx: Acute anterior STEMI late onset Killip 2,
Acute HF
 Rx: Aspirin 160mg (chewed), Clopidogrel 300mg,
ISDN 5 mg SL, simvaStatin 40mg orally
 We continued with anticoagulation by giving
Fondaparinux.
 We decided to perform fibrinolysis with 1.5 millions IU
of intravenous Streptokinase. In the process there were
bigeminy VPC, no other major complications of lytics
were observed. Afterwards the pain was decreasing to
4/10 and ECG evolved to Q waves.
 Then in his next 24 hours, the pain was resolved to
0/10.
 The third day of hospitalization, the echo was
evaluated.
1-H post lytics EKG
TTE
 echo showed LVEF of 46% with RWMA according to
his infarcted areas.
 and he was discharged home with dual antiplatelet,
statin, furosemide, ACE-I, and beta blocker.
Discussions
 Though no mortality benefit was demonstrated in the
LATE and EMERAS trials when fibrinolytic was routinely
administered to patients between 12-24 hours, we believe
that it is still reasonable to consider fibrinolytic therapy
when PCI is not available for appropriate patients with
clinical and/or electrocardiographic evidence of ongoing
ischemia within 12 to 24 hours of symptoms onset and a
large area of myocardium at risk.
 Persistent chest pain after the onset of symptoms correlates
with a higher incidence of collateral of anterograde flow in
the infarct zone and is therefore a marker for viable
myocardium that might be salvaged.