Presented by:

MUHAMMAD IDHAM BIN MOKHDZIR

Supervisor :
dr. Pendrik Tandean, Sp.PD KKV, FINASIM
Department of Cardiology and Vascular Medicine
Medical Faculty of Hasanuddin University
Makassar
2013

PATIENT IDENTITY
Medical Record
Name
Gender

Age
Address
Date of admission

: 622386
: Mr. IH
: Male
: 43 years old
: Sudiang
: August 18th 2013

HISTORY TAKING
Chief complaint:

Chest Pain
History of Present Illness:

The chest pain began since 4 days before he was admitted to Wahidin
Sudirohusodo Hospital. The sensation of chest pain suddenly appeared when the
patient was playing video game. The pain is described like dull heavy feeling on the
left part of the chest, not spreading . The chest pain felt continuously more than 20
minutes duration, and not relieved by rest. The chest pain was accompanied with cold
sweat and feeling nauseated. Theres no history of any chest pain before. Theres also
no history of fever, high blood pressure, and diabetes. History of any heart disease in
the family denied. Patient been smoking for almost 20 years with 12 cigarette each
days .
Patient has history of epigastric pain. Urination and defecation were normal.

HISTORY TAKING
History of Past Illness:

History of chest pain (-)

History of smoking ( + ) for 20 years

History of hypertension : denied

History of drinking alcohol (-)

No history of heart disease, No family history of heart disease

History of diabetes mellitus : denied

No history of dyslipidemia

No history of asthma

History of epigastric pain (+)

RISK FACTOR
Non
Modifiable
Gender: Male

Age: 43 yo

Modifiable

Smoking (+)

PHYSICAL EXAMINATION
General Status

Moderate illness/normal weight/conscious

Vital Signs
BP
: 110/60 mmHg
HR
: 82 bpm, regular
RR
: 20 tpm
Temp
: 36.6C
Weight : 60 kg
H eight : 166 cm

PHYSICAL EXAMINATION
Head Examination
Eyes
: Anemic -/-, Icterus -/ Lips
: Cyanosis (-)
Neck
: Lymphadenopathy (-), JVP R+0 cmH2O
Thorax Examination
Insp.
: Symmetrical R=L , normochest
Palp.
: Mass (-), tenderness (-), Vocal Fremitus R=L
Perc.
: Sonor
Ausc.
: Vesicular
Ronchi -/-,
Wheezing -/-

PHYSICAL EXAMINATION
Cardiac Examination

Insp. : IC not visible

Palp. : IC not palpable
Perc. : Dull
Right border : Right parasternalis line
Left border
: ICS 5 midclavicularis line
Ausc. : Pure regular of I/II heart sound, murmur (-)

PHYSICAL EXAMINATION
Abdominal Examination
Insp.
: Flat and following breath movement
Ausc.
: Peristaltic sound (+), normal
Palp.
: Liver and spleen is unpalpable
Perc.
: Tympani (+), ascites (-)
Extremities
Oedema : Pretibial -/-, Dorsum pedis -/-

ELECTROCARDIOGRAPHY

ELECTROCARDIOGRAPHY
Interpretation:
Rhythm
P-Rate
QRS-Rate
P-Wave
PR-Interval
QRS Complex
Axis
ST-Segment
T-Wave

: Sinus ritme
: x/m
: HR 68 bpm, reguler
: 0.12 sec
: 0.20 sec
: 0.08 sec
: Normal axis 50
: ST-elevation on lead I and AvL
ST-elevation on lead V2, V3, V4 , V5,V6
: Normal

Conclusion: Sinus Rythmn, HR 65 bpm, normoaxis . ST-elevation on

lead I ,AvL and lead V2-V6. Acute Extensive Myocardiac Infarct

LABORATORY EXAMINATION

WBC
HB
PLT
HCT
GDS
Ureum
Creatinin
Bil. Tot
Bil. Direct

: 17.71
: 14,1 gr/dl
: 300.000
: 38,1 %
: 131 mg/dl
: 19 mg/dl
: 1,1 mg/d
: 0,48 mg/dl
: 0,14 mg/dl

CK
CKMB
Trop. T
Na
K
Cl
SGOT
SGPT
Albumin
PT
APTT

: 5581 U/L
: 457 U/L
: >2.0
: 145 mmol/l
: 4,5 mmol/l
: 109 mmol/l
: 17 U/L
: 22 U/L
: 4,0 gr/dl
: 9.9
: 23.9

DIAGNOSIS
- STEMI Extensive Anterior with 4 hour onset

Killip I

INITIAL MANAGEMENT

Bed rest
O2 2-4 LPM (via nasal canule)
Heart Diet
IVFD NaCl 0,9% loading 500 cc/24 hours
Thrombolytic
Streptokinase (Streptase) 1.5 million IU in 100ml D5% within 1 hours
Anti Platelet Aggregation
ASA (Aspilet) loading dose 80 mg (2 x 80 mg) maintenance 1-0-0
Clopidogrel (Plavix) loading dose 75 mg (4 x 75 mg) maintenance 0-1-0
Anti cholesterol
HMG-Co A reductase inhibitor (Simvastatin 1 x 20 mg) 0-0-1
Anti coagulant

Low Molecule Weight Heparin(Fondaparinux(Arixtra)) 2,5 mg/24 jam/SC

Anxiolytic
Benzodiazepin (Alprazolam 1 x 0,5 mg)
Laxative
Laxadin syrup 1 x 2 cth
Anti hypertension
Ace-inhibitor (Captopril) 3 x 12,5 mg

PLANNING
Echocardiography
Coronary angiography

DIAGNOSIS OF CHEST PAIN

1
point

Retrosternal
or substernal
chest pain

1
point

Increased by
activity or
emotion

1
point

Relieved by
resting or
nitrate SL

3 point typical chest pain

Tend to be Stable Angina Pectoris than Acute Coronary
Syndrome

2 point atypical chest pain

Tend to be Acute Coronary Syndrome than Non
Cardiac Chest Pain

1 point or none non cardiac chest pain

DEFINITION
Acute Coronary Syndrome (ACS) is a term for
situations where the blood supplied to the heart

muscle is suddenly blocked.

describe 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).

CLASSIFICATION

PATHOPHYSIOLOGY

Vulnerable Plaque
Thrombosis
Vasospasme
Plaque disruption and
thrombosis that result in
complete coronary artery
occlusion leads to
transmural ischemia and
necrosis, the hallmark of
ST-segment elevation
myocardial infarction
(STEMI)

PATHOGENESIS
Lipid transport disorder

Inflamation

Plaque deposition

Erosion

Stable plaque

Plaque rupture

Thrombus

Acute coronary syndrome:

Unstable angina
Myocardial infarction :
- Non Q waves
- Q waves

Stable angina pectoris

Thrombosis

RISK FACTOR
Non- Modifiable

Modifiable

Gender and Age

Men, increased risk after age 45
Women, increased risk after age

Smoking
Hypertension

55
Family History
Heart disease diagnosed before

Diabetes Mellitus
Dyslipidemia

age 55 in father or brother

Heart disease diagnosed before

age 65 in mother or sister

Obesity
Lack of physical activity

DIAGNOSIS OF ACS
At least 2 of the following:
1. Ischemic symptoms

2. Diagnostic ECG changes

3. Serum cardiac marker elevations

1. ISCHEMIC SYMPTOMS
Prolonged pain (usually >20
minutes) constricting, crushing,
squeezing

Usually retrosternal location,

radiating to left chest, left arm; can
be epigastric

Dyspnea

Diaphoresis

Palpitations

Nausea/vomiting

2. DIAGNOSTIC ECG
CHANGES

ECG CHANGES
Timing of myocardial infarction based on ECG

3. SERUM CARDIAC MARKER

ELEVATIONS
Troponin
T

CK-MB

CK

SGOT

LDH

Myoglobin

CARDIAC BIOMARKER

DIAGNOSIS

WHO DIAGNOSTIC CRITERIA

Clinical history of ischaemic
type chest pain lasting >20
minutes

Changes in serial ECG tracings

Rise of serum cardiac

biomarkers such as creatinine
kinase-MB fraction and troponin

INITIAL MANAGEMENT

Fixing the chest pain and fearness

Bed rest
Diet
O2 2-4 lpm
Nitroglycerin: 0,4 mg SL tablets every 3-5 minutes up to 3 times; if effect is not
sustained, can continue with an IV drip of 50 mg in 250 ml dextrose 5%
Antiplatelet :
Aspirin: 162-325 mg chewed immediately and 81-162 mg continued indefinetely
Clopidogrel 300-600 mg loading dose and 75 mg daily continued for at least 14
days and up to 12 months.
Morphine 2-5 mg IV every 5-30 minutes
Pethidine 12,5 mg/IV
Diazepam 2-5mg/8 hour
Stabilizing the hemodynamic (blood pressure and pheripheral pulse control)
-blocker
Calcium channel blocker (CCB)
ACE-Inhibitor
Reperfusion of the myocard
Thrombolytic: streptokinase 1,5 million units/IV

PROGNOSIS
KILLIP CLASSIFICATION
Class

Description

Mortality Rate (%)

No clinical signs of heart failure

II

Rales or crackles in the lungs, an S3, and

elevated jugular venous pressure

17

III

Acute pulmonary edema

30 - 40

IV

Cardiogenic shock or hypotension

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

60 80