APRIL 2016

CASE REPORT:
ST SEGMENT ELEVATION
INFERIOR MYOCARDIAL INFARCTION
ONSET > 24 HOURS KILLIP II
Presented by:
Andi Saputri Majid

C111 12 057

Nurhafidah Mahfudz C111 12 058

Andi Idil Saputra
C111 12 059
Hartati Hamzi
C111 12 062

Supervisor:
Dr. dr. Abdul Hakim, Sp.PD, Sp.JP,
FIHA

PATIENT IDENTITY

Name

: Mr. B

Age

Address

: Mattoanging

MR

: 532990

Date of Admission : 19/4/2016

: 61 years old

HISTORY TAKING

Chief complaint

: Chest pain

Present Illness History :

Suffered since 1 day before admission

Described as burned and compressed pain on the left side

and radiating to left arm and neck, intermittently, duration of
pain : 20-30 minutes, accompanied with cold sweat.

The intensity is not influeced by activity or rest

Shortness of breath (+)

DOE (+)

PND (+)

Nausea (+), no vomitting

HISTORY TAKING

Past Illness History :

No history of hypertension

No history of Diabetes Mellitus

No history of alcohol consumption

History of smoking (+)

No history of previous chest pain and heart disease

No family history with heart disease

History of lung TB on 2015

RISK FACTOR
Modified Risk Factor
Smoking

Non-modified risk factor:

Gender : Male
Age : 61 years

PHYSICAL EXAMINATION

General Status

Moderate illness / Under Nutrition/ Composmentis

Weight: 45 kg

Height : 161 cm

BMI

: 17.37 kg/m2

Vital Status

Blood pressure

:120/70 mmHg

Heart rate

Respiratory rate

Temperature

: 100 bpm
: 28 rpm

: 36,5 oC

PHYSICAL EXAMINATION

Head : anemic (-) icteric (-)

Neck : JVP R+2 cmH2O,

Lung :
Inspection
Palpation
vocal
Percussion
Auscultation

: symmetry left=right
: mass (-), no tenderness, normal
fremitus
: sonor
: vesicular, ronchi +/+, wheezing +/+

PHYSICAL EXAMINATION

Cor

Inspection : ictus cordis not visible

Palpation : ictus cordis is palpable, thrill (-)

Percussion :
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea midclavicularis sinistra

Auscultation : heart sound I/II regular, murmur (-)

PHYSICAL EXAMINATION

Abdomen :

Inspection

Auscultation : peristaltic (+), normal

Palpation : liver and spleen not palpable

Percussion

Extremities :

Edema (-)

: flat, follows breath movement

: tympani

ELECTROCARDIOGRAPHY

Rhythm
Heart Rate
Regularity
P wave
PR interval
Axis

: sinus rhytm
QRS complex
: Q wave in II, III, aVF
: 91 bpm
Duration of QRS : 0.06 sec
: reguler
ST segment : elevation in II, III, aVF
: 0.06 sec
T wave
: T inverted in II, III, aVF
: 0.16 sec
: extreme right axis deviation Conclusion: STEMI

inferior

LABORATORY FINDINGS
TEST

RESULT

Normal value

RBC

4,67x106/l

4,50-6,50x106/l

WBC

19,4 x103 /l

4,0-10,0 x 103 /l

HGB

13,91 g/dl

14,0-18,0 g/dl

HCT

43,2%

40,0-54,0 %

PLT

236x 103 /l

150-400 x 103 /l

LABORATORY FINDINGS
Test

Result

Normal value

GDS

115 mg/dl

140 mg/dl

Ureum

41 mg/dl

10-50 mg/dl

Creatinin

1,25 mg/dl

M(<1,3);F(<1,1)
mg/dl

SGOT

13 U/l

<38 U/l

SGPT

9 U/l

<41 U/l

Natrium

135 mmol/l

136-145 mmol/l

Kalium

4,2 mmol/l

3,5-5,1 mmol/l

Klorida

103 mmol/l

97-111 mmol/l

LABORATORY FINDINGS
Test

Result

Normal value

CK

31 U/l

L(<190)P(<167) U/l

CK-MB

13 U/l

<25 U/l

Troponin I

0,05 ng/ml

<0,01 ng/ml

PT

10,9 detik

10-14 detik

aPTT

33,6 detik

22-30 detik

INR

1,05 detik

--

CHEST X-RAY
Conclusion:
- CTI 0,31 (normal)
- Active pulmonary TB
- Lymphadenopathy hilar
dextra

ECHOCARDIOGRAPHY
Normal left and right ventricular
systolic function
Concentric left ventricular
hypertrophy
Diastolic dysfunction grade I

DIAGNOSIS
1. ST Elevation Extensive Inferior Myocardial
Infarction (STEMI) onset >24 hours, KILLIP II
2. CAP, DD/ Syndrom Obstruction Post TB
3. Diastolic Dysfunction

TREATMENT

O2 2-4 L/min via nasal cannula

IVFD NaCl 0,9% 500 cc/24 hours

Aspilet 160 mg (loading dose), maintenance 1x80 mg tab
Clopidogrel 300 mg(loading dose), maintenance 1x75 mg
tab
Captopril 12,5 mg/12jam/oral
Bisoprolol 1.25mg/24jam/oral
Nitroglycerin 1mg/jam/ SP
Atorvastatin 40mg/24 hours/oral
Arixtra 2,5 mg/24 hours/subcutaneous
Laxadine syr 0-0-2 tsp
Alprazolam 0,5 mg 0-0-1

DISCUSSION

INTRODUCTION
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).

ACS Classification
20

Acute Coronary Syndrome

A. Unstable angina pectoris
B. NSTEMI
C. STEMI

Introduction
Myocardial ischemia is caused by
imbalance between myocardial oxygen
supply
and
myocardial
oxygen
consumption.
Myocardial infarction (MI) is the rapid
development of myocardial necrosis.

European Heart Journal. Guidelines on the management of stable angina pectoris

Regions of the Myocardium

Lateral
I, AVL,V5V6

Inferior
II, III, aVF

Anterior /
Septal
V1-V4

Pathophysiology

RISK FACTORS

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

CLINICAL PATHWAY

WHO DIAGNOSTIC CRITERIA

Ischemic
symptoms
Diagnostic
ECG
changes
Serum
cardiac
marker
elevations

Prolonged chest pain

Usually retrosternal location
Dyspnea
Diaphoresis

Inverted T wave
ST segment depression or elevation
Pathological Q wave

Troponin-T atau I
CK-MB
CK
Myoglobin

ISCHEMIC SYMPTOMS

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

CARDIAC BIOMARKERS

GOAL OF TREATMENT
Relieve
pain
Myocardial
reperfusio
n

Hemodyna
mic
stabilizatio
n
Prevent
the
complicati
on

Reperfusion Therapy for Patients with STEMI

*Patients with cardiogenic shock or severe heart failure initially seen at a nonPCI-capable hospital should be transferred for cardiac
catheterization and revascularization as soon as possible, irrespective of time delay from MI onset (Class I, LOE: B). Angiography and
revascularization should not be performed within the first 2 to 3 hours after administration of fibrinolytic therapy.

- Reperfusion Therapy -

Thrombolitik
ALTEPLASE
Alteplase 15 mg bolus iv.
50mg iv in 30minutes
35mg iv in 60minutes

TREATMEN
T
Relieve symptom
Vasodilatation NTG

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

Bisoprolol Clinical Study shows:

-Limit area of MI
-re-infarction risk decreas
-prolong life span

-Anti-remodelling
-decrease mortality
Captopril

TREATMENT

O2 2-4 L/min via nasal cannula

IVFD NaCl 0,9% 500 cc/24 hours

Aspilet 160 mg (loading dose), maintenance 1x80 mg tab
Clopidogrel 300 mg(loading dose), maintenance 1x75 mg
tab
Captopril 12,5 mg/12jam/oral
Bisoprolol 1.25mg/24jam/oral
Nitroglycerin 1mg/jam/SP
Atorvastatin 40mg/24 hours/oral
Arixtra 2,5 mg/24 hours/subcutaneous
Laxadine syr 0-0-2 tsp
Alprazolam 0,5 mg 0-0-1

ACC/AHA 2007 recommendation:

Loading: Aspirin 300mg
Decrease mortality
Clopidogrel 300mgDecrease re-infarction rate

CURE study reported:

Maintanance:
Aspirin 80mg+Clopidogrel 75mg (for1year)
decrease 20% mortality risk,
infark myocardial non fatal,
stroke

COMPLICATIO
N

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

III

Acute pulmonary edema

30 - 40

IV

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

60 80

6
17

THANK YOU

Hemostasis

INTRINSIC SYSTEM
HMWK
XII
XII a
Kallikrein
XI

XIa

EXTRINSIC SYSTEM
VII

IX
Ca 2+
PL

IXa + VIII
Ca 2+

TF
Ca 2+

Xa + V
Ca 2+
PL

Prothrombin

Thrombin
Fibrinogen

XIII

XIIIa

Fibrin

Stable fibrin clot

Ca 2+
44