CASE REPORT

ST Elevation Myocardial Infarction Inferior

Posterior Onset <12 hour KILLIP II

Presented by:
Nor Ezyan Syamin bt
Nor Yazmi
C 111 10 857
Supervisor:
dr. Abdul Hakim
Alkatiri, SpJP. FIHA

Medical Faculty of Hasanuddin University, Makassar 2015

Patients Identity
Name
Age
Address

: Mr. H
: 64 years old
: Jl. Cakalang/5 Pappang
Campalagian Polman
Medical Record
: 699862
Date of admission : 19th March 2015

Anamnesis
*Chest pain

Chief complaint

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Patient complaining about pain at the left side of the chest

since 3 hours ago. The pain described as being pressured,
continuous and radiating to the patients left arm and to the
back. The symptoms also accompanied by cold sweating.
Duration of the pain occured more than 30 minutes. The pain
aggravated by activities and does not relieve with resting. He
also complaint about dyspnea of effort , orthopnea, and
paroxysmal nocturnal dyspnea. There is no history of chest pain
before. He does not have any history of dyspnea. The patient
denied about having cough or fever. Heartburn have been
denied. Nausea and vomiting have been denied. There is no
abnormality in defecation and urination.

History of disease
History of lifestyle, smoking since 50 years
ago, 1-2 packs per day
Hypertension since 5 years ago and
uncontrolled
Diabetes Mellitus and cholesterol disease have
been denied
History of the same complaint have been
denied

Risk Factor
Non modified
Gender: Male

Modified
Hypertension

Age: 64 years Smoking

old

Physical examination
General status
GCS 15 (E4M6V5)
BW : 60 kg, BH : 165 cm, BMI : 22 kg/m2 (normal)
Moderate sickness / well nourished / conscious
Vital sign
BP: 120/80mmHg
Pulse : 72 bpm
Respiration rate : 20i/minute
Temp: 36,6 C

Physical examination
Head : anemic (-) icteric (-)
Neck : JVP R+2 cmH2O,
Lung :
Inspection
: symmetry left=right
Palpation
: mass (-), no tenderness, normal
vocal fremity
Percussion
: sonor
Auscultation : vesicular, ronchi +/+, wheezing -/-

Physical examination
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 : I/II pure heart sound , regular, murmur
(-)

Physical examination
Abdomen :
Inspection
Auscultation
Palpation
Percussion

: flat, follows breath movement

: peristaltic (+), normal
: liver and spleen not palpable
: tympani

Extremities : Edema (-)

Electrocardiography

Interpretation
Sinus : Rhythm
Heart Rate :68 bpm
P Wave : 0.1
PR interval : 0.16
QRS complex :0.08

Axis : Normoaxis
ST-segment : depression at

V2-V5
T Wave : Inverted at II, III, aVF
Conclusion : Rhythmic sinus,

heart rate 68 bpm, normoaxis,

ST-elevation at anterior region
and T inverted at inferior
region.

Electrocardiography (posterior)

Interpretation
Sinus : Rhythm
Heart Rate :74 bpm
P Wave : 0.1
PR interval : 0.16
QRS complex :0.08

Axis : Normoaxis
ST-segment : elevated at

V7-V9
T Wave : Inverted at II, III, aVF
Conclusion : Rhythmic sinus, heart rate 74 bpm,
normoaxis, ST-elevation at posterior region and
T inverted at inferior region.

Laboratorium (19/3/2015)
Complete Blood Count
Test

Result

Normal value

WBC

8,3 x 103 /mm3

4.0 10.0 x 103

RBC

5,58 x 106 /mm3

HGB

17,7 g/dl

12 16

HCT

50,5 %

37 48

PLT

180 x 103 /mm3

Insert text
4.0 6.0 x 10
here
6

150 400 x 103

Blood Chemistry
Test

Result

Normal value

Ureum

40 mg/dl

Creatinine

1,1 mg/dl

10 50
L(<1,3); P(<1,1)
mg/dl

SGOT

29 mg/dl

<38

SGPT

39 mg/dl

<41

Uric acid

10,5 mg/dl

P(2,4-5,7); L(3,4-7) mg/dl

Sodium

140 mmol/l

135 - 145 mmol/l

Potassium

4,3 mmol/l

3,5 - 5,1 mmol/l

Chloride

103mmol/l

97-111 mm0l/l

Cardiac Enzymes
Test
CK
CK-MB
Troponin-T

Result
116 U/l
166,6 U/l
0,56 ng/ml

Normal value
<190
<25
< 0,05

Diagnosis
ST elevasion myocardiac
infarction inferior posterior
KILLIP II

Management

Bed rest
O22-4 liter /minute via nasal canule
IVFD NaCl 0,9 % 500 cc/24 hours
Anti-Platelet Agregation
Aspilet 160 mg (loading dose), maintenance 1x80 mg tab
Clopidogrel 300 mg(loading dose), maintenance 1x75 mg tab

Nitrat
Isosorbid dinitrate (Farsorbid) 10mg/8hours/oral
Isosorbid dinitrate 5mg/chest pain occurrence/subligual

Anti-coagulant
Fondaparinux (Arixtra)2.5mg/24hours/subcutaneous

Anti Hypertension/ anti-remodelling

Captopril 6,25 mg/ 8 hours/ oral

Laksative
Laxadyn syrup 15cc/24hours/oral

Anti-anxiety
Alprazolam 0.5mg/24hours/oral
Thrombolitic
Streptokinase 1,5 million unit in Dextrose 5% 100 ml finish in an hour

Discussion
Acute Coronary Syndromes
(ACS)

Regions of Myocardium
Lateral
I,
AVL,V5V6

Inferior
II, III, aVF

Anterior /
Septal
V1-V4

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

Pain Assessment
Onset: What was the patient doing when the signs and
symptoms first occurred?
Provocation: Is there anything that makes the symptom
better or worse?
Quality: Description of what the patient is feeling for
example the pain can be described as dull, sharp,
crushing, aching, tearing
Radiation/Region: Where is the pain located and does it
move to another part of the body?
Severity: How severe is the symptom based on a scale 1
to 10
Time: When did the signs and symptoms first occur?

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Pathophysiology

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Risk Factor
Modifiable
Smoking
Hypertension
Diabetes mellitus
Hypercholesterolemi
a
Obesity
Psychosocial stress
Lack of physical
activity

NonModifiable
Gender & Age
Men > 45 years old
Women > 55 years old

Family history
Heart disease in
biological brother or
father > 55 years old
Heart disease in
biological sister or
mother > 65 years old

DIAGNOSIS OF ACS
At least 2 of the following
Ischemic symptoms
Diagnostic ECG changes
Serum cardiac marker
elevations

DIAGNOSIS OF ACS
Ischemic symptoms
Prolonged pain (usually >20 mins) may also be
described as a dull pain, constricting, crushing, squeezing
Usually retrosternal location, radiating to left chest,
left arm; can be
epigastric
Dyspnea
Diaphoresis
Palpitations
Nausea/vomiting
Light headedness
Sense of impending doom

DIAGNOSIS OF ACS
At least 2 of the
following
Ischemic symptoms
Diagnostic ECG
changes
Serum cardiac
marker
elevations

ECG CHANGES

Hyperacute
Phase

Complete
Evolution

Non specific STElevation

T taller and wider

Specific STElevation
T inverted
Q-Pathologic

Old Infarct
Q-Pathologic
ST segment
isoelectric
T normal or
inverted

DIAGNOSIS OF ACS
At least 2 of the
following

Troponin T

Ischemic

CK-MB

symptoms

CK

Diagnostic ECG

Myoglobin

changes
Serum cardiac
marker

CARDIAC BIOMARKERS

MANAGEMENT

Complications
Systemic

Cardiogenic shock
Severe heart failure
Right ventricular infarction

Mechanic
al

Electrical

Ventricular arrythmia
Atrial Fibrilation and Other Supraventricular
Tachyarrhythmias
Bradicardia, Atrioventricular block

Others

Mitral regurgitation
Ventricular septal rupture
Left ventricular free wall rupture
Left ventricular aneurysm

Pericarditis
Thromboembolic & bleeding
Acute kidney injury
Hyperglycemia

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

Animated Cardiogram PPT Template

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Thank
You

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