Recent STEMI

Extensive
Anterior Wall
KILLIP II

Supervisor: Prof. dr. Peter Kabo, Ph.D,

Sp.FK, Sp.JP(K), FIHA, FAsCC

Ningrum Sekarsari Rauf C01

Andi Rahim Nur Annura Anggarha C014182230

Sausan Maulida C014182231

PATIENT IDENTITY

• Name : Mr. T
• Gender : Male
• Age : 44 years old
• Address : Griya Alam Towuti
• MR : 894307
• Date of Admission : September 4th 2019
 HISTORY TAKING

• Chief Complaint : Chest pain

• Present illness history
The patient is reffered from Sorowako Hospital. Patient complain chest pain that spread
untill the back and epigastrium >20 minutes every morning since 3 days before admission in
the Sorowako hospital. The chest pain not relieved by rest. Chest pain reduced when patient
arrived in Integrated Heart Center (PJT). The chest pain accompained with palpation, cold
sweat and vomitting. There are dyspneu, no orthopneu, and no PND (Paroxysmal Nocturnal
Dyspneu), no fever, and no cough, no edema. Defecation and urination are normal.
PAST ILLNESS HISTORY

o History of hypertension and high cholesterol since 10 years ago

but did not take medicine regularly.

o History of diabetes mellitus is denied

o No history of cardiovascular disease before

RISK FACTOR

o No history of smoking
o No history of alcohol consumption
o History of heart disease in family (patient’s uncle died with heart failure)
o History of stroke and DM disease in family (patient’s parent)
PAST MEDICAL HISTORY
(in Sorowako Hospital)

o Aspilet 80mg/24 hours

o Clopidogrel 75 mg/24 hours
o Ramipril 5mg/24 hours
o Atorvastation 40mg/24 hours
PHYSICAL EXAMINATION

• GENERAL STATE
o Moderate illness/compos mentis

• VITAL STATE
o Blood Pressure : 120/80 mmHg
o Heart Rate : 100x/min
o Respiratory Rate : 20x/min
o Temperature : 36.6°C
PHYSICAL EXAMINATION

Head : Normocephalic
Eye : Anemis (-), icteric (-)
Pupil : equal, round, diameter 2,5 mm, reactive to light
Nares : normal
Lip : no cyanosis
Neck : JVP R+2CmH20, no lymphadenopathy, no thyroid enlargement
PHYSICAL EXAMINATION

Chest Examination
Inspection : symmetry left = right
Palpation : mass (-), tenderness (-)
Percussion : sonor, left = right
lung-liver border in ICS VI anterior
Auscultation : breath sound: vesicular.
Additional sound: ronchi (+/+) in basal pulmonary,
wheezing (-/-)
PHYSICAL EXAMINATION

Cor
Inspection : ictus cordis does not seem
Palpation : ictus cordis palpable, thrill (-)
Percussion :
Upper border 2nd ICS linea parasternalis sinistra
Right border 4th ICS linea parasternalis dextr
Left border 5th ICS linea axillaris anterior sinistra
Auscultation : heart sound I/II pure, regular, murmur (-)
PHYSICAL EXAMINATION

Abdominal Examintation
Inspection : Convex, following breath movement
Auscultation : Peristaltic sound (+), normal
Palpation : Mass (-), tenderness (-), no palpable liver and spleen
Percussion : Timpani (+), Ascites (-)

Extremitas Examination
Warm extremity
Pretibial edema none
Dordum pedis edema none
ELECTROCARDIOGRAPHY
LABORATORY FINDINGS
(04/09/19)

TEST RESULT NORMAL VALUE

WBC 18.68 x 103 4 - 10 x 103/uL
RBC 5.45 x 106 4 – 6x106/uL
HGB 14.3 12 - 16 g/dl
ROUTINE HCT 43.1 37 - 48 %
HEMATOLOGY MCV 79.1 80-100 um3
MCH 26.2 27-32 pg
MCHC 33.2 32-36 g/dl
PLT 296 x 103 100 - 300 x 103/Ul
LABORATORY FINDINGS
(04/09/19)

Test Type Result Normal value

Koagulasi PT 10.8 seconds 10 – 14 seconds

INR 1.04 --
APTT 26.5 seconds 22.0 – 30.0 seconds
Glukosa GDS 110 mg/dl 140 mg/dl
Renal Function UREUM 17 mg/dl 10 – 50 mg/dl

KREATININ 0.76 mg/dl L(<1.3);P(<1.1) mg/dl

Liver Function SGOT 84 U/L <38 U/L
SGPT 66 U/L <41 U/L
Immunoserology Hs TROPONIN I >40000 8-29 ng/ml

Electrolyte NATRIUM 137 mmol/l 136 – 145 mmol/l

KALIUM 4.1 mmol/l 3.5 – 5.1 mmol/l
KLORIDA 103 mmol/l 97 - 111 mmol/l
RADIOLOGY FINDINGS
(04/09/19)

• Homogen Consolidation with

airbronchogram sign in the middle of right
lung
• CTI: normal, aorta normal
• Both of diaphragma sinus are normal
• Bones are intake
• No soft tissue swelling

Impression :
• Pneumonia dextra
ECHOCARDIOGRAPHY
(04/09/19)

Conclusion
Sufficient Left Ventricle Systolic function, EF 47% (Biplane)
Concentric left ventricle hypertrophy
Segmental akinetic and hypokinetic
Mild Left ventricle diastolic disfunction
DIAGNOSIS

Recent ST Elevation Myocardial Infarction (STEMI)

Extensive Anterior Wall KILLIP II
TREATMENT

Bed rest
IVFD NaCl 0,9% 500 cc/24 hours/IV
1. Anti agregation Platelets: Aspilet 80 mg/24 hours/ oral
2. Anti agregation Platelets: Clopidogrel 75 mg/24 hours/oral
3. Statin: Atorvastatin 40 mg/24 hours/oral
4.Anti Coagulant: Arixtra 2,5mg/24 hours/Subcutan
5. Nitrate: Isosorbid Dinitrat 5 mg/Sublingual
6. Diuretic: Furosemide 40mg/12 hours/IV
7. B-Blocker: Concor (Bisoprolol) 1,25 mg/ 24 hours/ oral
DISCUSSION

Recent ST Elevation Myocardial Infarction (STEMI)

Extensive Anterior Wall KILLIP II
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
PATHOPHYSIOLOGY
Atherosklerosis, trombosis at coronary arteries

Decrease the blood flow into

the heart

Decrease the supply of

oxygen and nutrition

Ischemia myocard

Necrosis

Imbalance supply and consumption of the oxygen

into the heart

Myocardial infarction
 REGIONS OF MYOCARDIUM

Lateral
I, AVL,V5-V6

Inferior
II, III, aVF Anterior / Septal
V1-V4
RISK FACTORS

Non-Modifiable Modifiable

o Gender o Smoking

o Age o Hypertension
o Family History o Diabetes Mellitus

o Dyslipidemia

o Obesity
DIAGNOSIS

Sign of myocardial ischemia

ECG
Yes
STEMI (ST Elevation Myocardiac
ST segment elevation?
Infarction)

No Lab
Yes
NSTEMI (Non ST Elevation
↑Biochemical cardiac markers?
Myocardiac Infarction)

No
Unstable Angina
DIAGNOSIS OF ACS

At least 2 of the following

o Ischemic symptoms
o Troponin T
o Diagnostic ECG changes
o CK-MB
o Serum cardiac marker
o CK
o elevations
ISCHEMIC SYMPTOMS

o Prolonged pain (usually >20 mins), may also be described as a dull pain, constricting,
crushing, squeezing
o Usually retrosternal location, radiating to left chest, left arm; can be epigastric
o Not fully relieved by rest or nitroglicerine
o Dyspnea
o Diaphoresis
o Palpitations
o Nausea/vomiting
o Light headedness
ECG CHANGES

Hyperacute Phase Complete Evolution Old Infarct

• Non specific ST- • Specific ST-Elevation • Q-Pathologic
Elevation • T inverted • ST segment isoelectric
• T taller and wider • Q-Pathologic • T normal or inverted
CARDIAC BIOMARKER
Unstable Angina NSTEMI STEMI

Occluding
thrombus Complete thrombus
Non occlusive sufficient to cause occlusion
thrombus tissue damage &
mild ST elevations on
Non specific myocardial necrosis ECG
ECG
ST depression +/- Elevated cardiac
Normal cardiac T wave inversion on enzymes
enzymes ECG
More severe
Elevated cardiac symptoms
enzymes
GOAL OF TREATMENT

Hemodynamic
Relieve pain
stabilization

Myocardial Prevent the

reperfusion complication
MANAGEMENT
 INITIAL TREATMENT
o Bed rest o Fibrinolytic therapy:
o Oxygen (2-4 lpm) • Streptokinase 1.5 million units in 100 mL dextrose
5% or NaCl 0,9% finished in 30 – 60 minutes
o Anti platelet therapy : • Actilyse : 15 mg bolus iv, 0.75mg/kg weight body
• Aspirin 160-320mg chewed immediately and 80-160 in 30 minutes and 0,5 mg/kg weight body in 60
mg continued indefinitely. minutes
o Anticoagulation therapy:
• Clopidogrel 300-600mg loading dose and 75mg daily • Low Molecular Weight Heparins (Fluxum) 0.4cc/sc
continued for at least 14 days and up to 12 months. for up to 8 days post-MI.
o Nitroglycerin : o Unfractionated heparin
o Anti Hypertension Drugs
• 0.4 mg SL tablets every 3-5 min up to 3 times; if o Lipid Lowering Agents
effect is not sustained, can continue with an IV drip
of 50mg in 250mL Dextrose 5%.
o Morphine 2-5mg iv (can be administered again in 5-30
minutes later)
PROGNOSIS
KILLIP CLASSIFICATION

CLASS DESCRIPTION MORTALITY RATE (%)

I No clinical signs of heart failure 6

Rales or crackles in the lungs, an S3, and

II 17
elevated jugular venous pressure

III Acute pulmonary edema 30 - 40

Cardiogenic shock or hypotension (systolic

IV BP < 90 mmHg), and evidence of peripheral 60 – 80
vasoconstriction
COMPLICATIONS
THANK YOU