CASE REPORT

ST Elevation Myocardial
Infarction (STEMI) Inferior
Presented by : Eka Reskiana Widhiasnasir (C11114091)
Supervisor : dr. Pendrik Tandean, Sp.PD-KKV., FINASIM
Patient Identity

 Name : Mr. MH
 Age : 61 years old
 Address : BT. Bungin II Makale
 MR : 837054
 Date of Admission : 20/03/2018
 History Taking

• Chief Complaint : Chest Pain

• It was felt since 3 days before admitted to the hospital. The pain felt
like a cramp with heavy intensity and shortness of breath. Chest pain
among >30 minutes cold sweat. History of uncontrolled hypertension.
History of smoking since in Junior high school and stopped 6 years
ago. Cough (-), Family history with hypertension.
Physical Examination

 General status : good/ compos mentis

 Nutritional status : BB = 86 kg ;TB = 172 cm, IMT + 29
kg/m2(obes I)
 Vital sign : BP= 135/80 ; Pulse= 100 bpm; RR = 20
x/minute; Temperatur= 36.5ºC
Physical Examination

 Head and neck examination

Eye : anemic conjunctiva (-), icteric sclera (-)
Lip : cyanosis (-)
Neck : JVP R +H2O, submandibular & tyroid enlargement
(-)
Physical Examination

 Chest examination
Inspection : symmetric between left and right chest
Palpation : no mass, no tenderness
Percussion : sonor between left and right chest, Lung-
Liver right junction in ICS 6
Auscultation : respiratory sound = vesicular, ronchi (-),
wheezing (-)
Physical Examination

 Hearth examination
Inspection : hearth apex was not visible
Palpation : hearth apex was not palpable
Percussion : : Upper Heart Border in left ICS II
Right heart border in ICS 4 right parasternal line
Left heart border in ICS 5 left midcaxillaris line
Auscultation : hearth sound : SI/II irregular, murmur (-)
Physical Examination

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

 Extremitas examination
Edema (-)
Laboratory Finding
Pemeriksaan Hasil Nilai Normal
WBC 12.99 [10^3/mm3] 4.0 - 10.0
RBC 4.73 [10^6/mm3] 4.50 - 6.0
HGB 13.5 g/d 12.0 – 16.0
HCT 39.5% 37.0 – 48.0
MCV 83.5 fL 80.0 – 97.0
MCH 28.5 pg 26.5 – 33.5
PLT 310 [10^3/mm3] 150 - 400
PT 10.0 detik 10 – 14
INR 0.91 -
APTT 24.6 detik 22.0 – 30.0
Ureum 32 mg/dl 10 – 50
Creatinine 1.04 mg/dl < 1.3
SGOT 49 U/L < 38
SGPT 60 U/L < 41
Laboratory Finding

CK 297.32 U/L < 167 U/L

CK-MB 25.7 U/L < 25
Troponin I 5.49 ng/ml < 0.01
Kolestrol total 171 mg/dl 200 mg/dl
Kolesterol HDL 35 mg/dl >55 mg/dl
Kolestrol LDL 107 mg/dl <130 mg/dl
Trigliserida 100 mg/d1 200 mg/dl
Asam urat 8.0 mg/dl 3.4-7.0 mg/dl
Natrium 140 mmol/l 136 – 145
Kalium 4.2 mmol/l 3.5 – 5.1
Klorida 106 mmol/l 97 – 111
 Electrocardiogram (20/03/2018)

Supraventricular tachycardia, HR 110 bpm, irregular, normoaxis, right

bundle branch block, inferior myocardial infarction, extrasystol atrium
Echocardiography (20/03/2018)

 Decrease left and right ventricle systolic function, EF

37.5%
 Concentric left ventricle hypertrophy
 Segmental hypocinetik
 Mild to moderate mitral regurgitation
Chest X-Ray (20/03/2018)

 Cardiomegaly and aortic dilation and

elongation
Diagnose

 ST elevation myocardial infarction

 Atrial fibrillation tachycardia ventricular respond
 Hypertension on treatment
Management

 NaCl 0,9% (500 ml/24 hours/intravena)

 Antiplatelet agent : Aspilet 160 mg/ loading dose, 80mg/24 hours/ oral
(maintenance)
 Antiplatelet agent : Clopidogrel 300/ loading dose, 75 mg/24 hours/oral
(maintenance)
 Anticoagulant : Fondaparinux (Arixtra 2,5 mg/24 hours/Subcutan)
 Nitrat : Nitroglycerin 10 mcg/24 hours/ sublingual
 ACE-i : Ramipril 5 mg/24 hours/oral
 Statin : Atorvastatin 40 mg/24 hours/oral
 ᵝ Blocker : Bisoprolol 1,25 mg/24 hours/oral
DISCUSSION
Definition of STEMI

 ST-elevation myocardial infarction (STEMI) is one of the major causes of

mortality and morbidity in the world. STEMI is part of the acute coronary
syndrome, which also includes non-elevation myocardial infarction and
unstable angina pectoris. The Europian Society of Cardiology defines STEMI
as an increase and / or decrease in cardiac biomarkers at least with one of
ischemic symptoms, ST segment changes in electrocardiography (ECG) or
new left bundle branch block (LBBB), pathological Q waves, loss of
myocardial image in imaging and presence intracoronary thrombus on
examination of coronary angiography (Steg G, 2012)
Risk Factor

 Modifiable  Non-Modifiable
 Smoking  Age
 Diabetes Mellitus  Gender
 Dyslipidemia  Genetic
 Obesity
 Hypertension
 Physical inactivity
Patophysiology
Diagnose

 History Taking
• Chest pain/angina
• Appears at rest or during mild activity
• Feels retrosternal and radiates to the arms, neck, jaw
• Can also be accompanied by cold sweat, dyspnea, weakness, nausea,
abdominal pain, or syncope
Diagnose

 Physical Examination
• Cyanosis
• Tachycardia, hypotension ( anterior)
• Bradycardia, hypotension (inferior)
• S4 & S3 gallop
• Paradoxical split S2
• Mid systolic murmur/late systolic apical
 Diagnose

 Electrocardiogram (10 minutes)

• ST elevation

Septum : V1, V2 Inferior : II, III, aVF

Anterior : V3, V4 Anteroseptal : V1, V2, V3, V4
Lateral : V5, V6 Anterolateral : I, aVL, V3, V4, V5, V6
Posterior : V7 – V9
Diagnose

 Biomarkers
• Injured myocard cell release protein and enzim  cardiac biomarker
normally not found in blood cerum
• Tropnin T & I elevate in 4-6 hurs, stays in 4-7 days (I) and 10-14 days (T),
false positive in musculosletal injury
• CKMB released 4-6 hours and elevates 48-72 hours
Diagnose
Management

 Reperfusion treatments (onset <12 jam, persistent ST elevation and new

LBBB)
• PCI
Pre-PCI  aspirin 160 mg loading dose, ticagrelor 180 mg loading dose /
klopidogrel 600 mg loading dose
• Fibrinolytic
Tenekteplase, alteplase, reteplase
• Anticoagulant
Enoksaparine, fondaparinuks,
 Beta-blockerbeta-1 receptormyocard O2
Anti ischemia
consumption decreased

Nitratvasodilatationdecrease preload and end

Nitrogliserin diastolic of left ventricel myocard O2 consumption
decreased

Aspilet loading dose 150-300 mg and maintanance

Antiplatelet of 75-100 mg /day
Clopidogrel loading dose 600 m maintainance 75mg

Anticoagulant Fondaparinox 2.5 mg/day subcutaneous

Inhibitor hydroxymethylglutary-coenzyme A
Statin
reductase 40 mg
Thank You