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ST ELEVATION

MIOCARD INFARCT
Presented by :
1. Ayu Aqilah Binti Khazani
2. Nurul Dhiya Binti Hassannuddin
3. Narisa Samaradhantia

Supervisor :
Dr .dr. Khalid Saleh SpPD-KKV, FINASIM
 Name : Mr. P. A

 Age : 47-year-old

 Address : Pare – pare

 Gender : Male

 Mariatal status : Married

 MR : 781791

 Date of Admission : 07/12/2016


 Chief complaint : Chest pain
 Present Illness History :
 Left chest pain felt since 6 hours before admission while the patient
is resting.
 Pain described as compressed pain and radiating to left arm
 duration of pain : 15- 20 minutes
 Nausea and cold sweating is present
 Dyspnea (-)
 No fever, cough and vomiting
 Micturition and defecation are normal
 Past Illness History :
 History of hypertension - denied
 History of Diabetes Mellitus - denied
 No family history with heart disease
 No history of chest pain before

 Lifestyle History:
 History of smoking (+) 2 packs per day since highschool
 No history of alcohol consumption
 General Status
 Moderate illness / Overweight / Composmentis
 GCS : 15 (E4M6V5)
 Weight : kg
 Height : cm
 BMI : kg/m2

 Vital Status
 Blood pressure :120/80 mmHg
 Heart rate : 64 bpm
 Respiratory rate : 24 rpm
 Temperature : 36,5 oC
 Head : anemic (-) icteric (-)
 Neck : JVP R+1 cmH2O,
 Lung :
 Inspection : symmetry left and right
 Palpation : mass (-), no tenderness, normal vocal fremity
 Percussion : sonor
 Auscultation : vesicular, ronchi -/-, wheezing -/-
 Cor :
 Inspection : ictus cordis not visible
 Palpation : ictus cordis not 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 (-)


 Abdomen :
 Inspection : flat, follows breath movement
 Auscultation : peristaltic (+), normal
 Palpation : liver and spleen not palpable
 Percussion : tympani

 Extremities :
 Edema (-)
Sinus rhythm
I Heart rate : 58bpm
II Axis : Normoaxis (45°)
P Wave : 0,08s
III
PR interval : 0,12 s
AVR QRS complex : 0,08s
AVL ST segment : ST elevation on lead
AVF
V1, V2 ,V3,V4
T Wave : normal
V1

V2
V3 Conclusion :
V4
Sinus rhytm, HR 58x/mnt,
normoaxis, STEMI Anteroseptal
V5

V
6
TEST RESULT NORMAL VALUE

GDS 198mg/dL <140


TEST RESULT NORMAL VALUE
SGOT 114 u/L <38
WBC 14,4 x 103/uL 4.0 – 10.0 x 103
SGPT 35 u/L <41
RBC 5,01 x 106/uL 4.0 – 6.0 x 106
Ureum 23 mg/dL 10-50
HGB 14,1 g/dL 12 – 18
Kreatinin 1,25 mg/dL 0,5-1,2
HCT 44,6% 37 – 48
CK 1878,00 u/L <190
PLT 333 x 103/uL 150 – 400 x 103
CKMB 147,3 u/L <25
Trop I 3,88 <0.01
Natrium 146 mmol/L 136 - 145
Kalium 3,4 mmol/L 3,5 - 5,1
Klorida 105 mmol/L 97 - 111
TEST RESULT NORMAL VALUE

Total Cholesterol 190 mg/dl 200

HDL 25 mg/dl > 55

LDL 142 mg/dl < 130

TRIGLYCDERIDE 160 mg/dl 200


 Echocardiography
 Cek Profil Lipid
 Catheterization
Chest pain felt since 6 hours before admission to the hospital. The pain radiating to
the back and the left arm. Cold sweating during the chest pain. The patient felt
nausea. GDS : 198 mg/dl, SGOT : 114 ul, CK : 1878,00 ul, CKMB : 147,3 ul. Troponin :
3,88 ng/ml, Na : 146 mmOl/L. LDL : 142 mg/dl, HDL : 25 mg/dl. ECG Sinus
anteroseptal. History of smoking since 20 years ago (more thsn 2 pack/day).
ST Elevation Inferior Myocardial Infarction
(STEMI) onset <12 hours, KILLIP I
 IVFD NaCl 0,9% 500 cc / 24 hours / intravena
 Aspilet 80 mg / 24hours / oral
 Brilinta 90mg /12 hours / oral
 Farsorbid 10 mg / 8 hours / syringe pump
 Arixtra 2,5 mg / 24 hours / subcutaneous
 Acetyl cysteine 400mg / 12 hours / oral
 Atorvastatin 40mg / 24 hours / oral
 Bisoprolol 1,25 mg / 24jam / oral
 Captropril 6,25mg / 8 hours / oral
 Laxadine syrup 10cc / 24 hours / oral
 Alprazolam 0,5 mg / 24 hours / oral
 ACUTE MYOCARDIAL INFARCTION (MI) is the term used for cell
death secondary to ischemia.
 Common cause of MI is atherosclerotic narrowing of the coronary
arteries.
 The immediate precursor to MI is rupture of an atherosclerotic plaque
and the formation of thrombus over the plaque, resulting in rapid
occlusion of the vessel.
 Depending upon the rate of vessel occlusion dan the degree of
occlusion of the vessel by thrombus, a number of clinical conditions
can result plaque rupture.
 These conditions are termed the acute coronary syndrome.
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).
Unstable
Angina NSTEMI STEMI

Occluding thrombus Complete thrombus


Non occlusive sufficient to cause occlusion
thrombus tissue damage & mild
myocardial necrosis ST elevations on
Non specific ECG or new LBBB
ECG ST depression +/-
T wave inversion on Elevated cardiac
Normal ECG enzymes
cardiac
enzymes Elevated cardiac More severe
enzymes symptoms
Non-
Modifiable
Modifiable
Smoking Gender & Age
Hypertension • Men > 45 years old
Diabetes mellitus
• Women > 55 years old

Hypercholesterolemia Family history


Obesity • Heart disease in biological
brother or father > 55 years old
• Heart disease in biological
Psychosocial stress sister or mother > 65 years old

Lack of physical activity


Hyper acute Complete Old Infarct
Phase Evolution • Q-Pathologic
• Non specific ST- • Specific ST-Elevation • ST segment
Elevation • T inverted isoelectric
• T taller and wider • Q-Pathologic • T normal or inverted
Initial diagnosis and early risk stratification

Relief of pain, breathlessness, and anxiety

Restoring coronary flow and myocardial tissue


reperfusion

Prevent the complication


TREATMENT
Clinical Study shows:
Bisoprolol -Limit area of MI
-re-infarction risk decrease
-prolong life span
Relieve symptom
NTG
Vasodilatation

-Plaque stabilization
-LDL decrease Atorvastatin
target: <70mg/dl -Anti-remodelling
-decrease mortality

Captopril
ACC/AHA 2007 recommendation:
Loading: Aspirin 300mg Decrease mortality
Decrease re-infarction rate
Clopidogrel 300mg

CURE study reported:


Maintanance:
Aspirin 80mg+Clopidogrel 75mg (for1year)

decrease 20% mortality risk,


infark myocardial non fatal,
stroke
COMPLICATION
MORTALITY RATE
CLASS DESCRIPTION
(%)

I No clinical signs of heart failure 6

Rales or crackles in the lungs, an


II S3, and elevated jugular venous 17
pressure

III Acute pulmonary edema 30 - 40

Cardiogenic shock or
hypotension (systolic BP < 90
IV 60 – 80
mmHg), and evidence of
peripheral vasoconstriction