Cardiology Department

Medical Faculty
Hasanuddin University

Case Report
April 2013

STEMI Inferior
Case Report >24 Jam
Onset
Killip II
Austein Wedyanto

C 111 08 346

Supervisor:
dr. Muzakir Amir, Sp.Jp.FIHA FICA

HASANUDDIN UNIVERSITY
MAKASSAR
2013

Patients Identity
Name

Mr. D

Gender

Male

Age

69 years old

Address

Riso Enrekang

Medical Record No.

599669

Date of Admission

March 18th 2013

History Taking
Chief Complain

: Chest Pain

It was felt 28 Hours before admitted to the hospital,

penetrated to back and radiated to left arm. It was felt for
more than 20 minutes and didnt relieve by taking a rest.

During the attack, patient feel sweating, nausea,

vomit (-), palpitations (+), shortness of breath (+).
Cough (-), history of cough(-)
Dizziness (-), Headache (-) , Fever (-)
PND (-), DOE (+)
Defecation and urination : normal

Previous Illness

History of coronary heart diseases (-)

History of Hypertension and uncontrolled (+)
History of diabetic (-)
Asthma (-), family history with asthma (-)
Family history with CVD (-)
Cigarette smoking (+), 1-2 pack each day
Alcoholism (-)

Physical Examination
General status:
Moderate Ilness/ Overweight/Conscious (Alert and
Oriented)
Body Weight
: 60 kg
Body Height
: 165 cm
Body Mass Index
: 22,8 kg/m2

Vital Status

Blood Pressure : 140/100 mmHg

Heart Rate
: 72 x/mnr
Respiratory Rate
: 26 x/mnt
Body Temperature
: 36,5 C

Physical Examination
Head :
Normochepalic
Eye :
Anemis (-), Icteric (-)
Pupil :
Equal, round, diameter 2,5 mm,
reactive to light
Nares:
Appearent is normal
Mouth
:
No cyanosis
Neck :
JVP +3 CM H2O, no lymphadenopathy,
no thyroid enlargement

Physical Examination
Lung

Inspection
Palpation:
Percussion
Auscultation

:
Equal expension bilaterally
No tenderness, no mass palpable
:
Normal resonance bilaterally
:

Breath Sounds
: Vesicular
Adventitious breath sound
: Ronchi (-) , No
wheezing

Physical Examination
Cardiac Examination
Inspection : Ictus cordis was invisible
Palpation : Ictus cordis was palpable in ICS V
about 1 finger from lateral of medioclavicularis
sinistra line, Thrill (-)
Percussion : Right heart border in right
parasternalis line, left heart border in left
midclavicle line ICS V.
Auscultation
: Heart Sounds = S I/II regular.

Physical Examination
Abdominal

Inspection: Flat, following breath movement

Auscultation: Peristaltic sound (+), normal
Palpation : Liver and spleen are unpalpable
Percussion
: shifting dullness (-)

Extremities
Oedema pretibial -/ Oedema dorsum pedis -/ Cyanosis (-), Clubbing finggers (-)

ECG Finding
(18/03/2013)

Rhythm
: Junctional rhythm
P wave
: Invisible P wave
Heart Rate
: 72/minutes
Duration QRS
: 0,06 s
Axis
: 105 Degree
ST Segment
: ST Elevation at Lead II,III,
AVF. ST depresi at AFL, Lead I, V4, V5, V6
T wave
: T Inverted Lead II, III, AVF

CONCLUSION :
1. Junctional Rhythm
2. STEMI Inferior

Laboratory Findings
1/03/13
WBC

13,09 x 103

Na

142

RBC

5,27 x 106

4,7

HGB

15,3

Cl

107

HCT

46,5%

PT

11,3

PLT

204

APTT

26,5

Ur

67

GDS

111

Cr

1,3

SGOT

816

CKMB

675

SGPT

135

Trop T

>2,0

Echocardiography
findings

LV systolic function
decrease, EF 42%
Dilated LA and LV
Hypokinetic at Inferior,
inferoseptal and inferior
No LVH
RV Function decrease,
TAPSE 0,9 cm
Mpa 30 mmHg
Heart valves :

Mitral : MR Mild
Aorta : no calcification
Trikuspid : TR Mild
Pulmonal : function and
motility are good

Conclusion :
1. Diastolic and
systolic of both
ventricle
disfunction
2. Hypokinetic at
Inferior,
Inferoseptal and
posterior
3. MR, TR, PH
Mild

Working Diagnosis
STEMI Inferior onset > 24Hours Killip II
HT Grade I

Therapy

Bed Rest
O2 3 4 liter/min via nasal canule
Heart Diet
IVFD NaCl 0,9% 1000cc/24 hours
(Salysilic Acid) Aspilet 80 mg 1-0-0
(Clopidogrel) Plavix 75 mg 0-1-0
(ACE Inhibitor) Captopril 25 mg 1-0-1
(Statin) Simvastatin 20 mg 0-0-1
(Fondaparinux sodium) Arixtra 2,5 mg/24 hours/SC
(Isosorbide dinitrate) Cedocard 5mcg/minutes via
syringe pump
Alprazolam Tab 0,5 mg 0-0-1
(Bisacodyl)Laxadyn syrup 0-0-2

Management
Planning
ECG Control
Coronary angiography

Discussion
STELEVATIONMYOCARDIAL
INFARCTION

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
Occurs when

coronary blood flow

decreases abruptly
after a thrombotic
occlusion of a
coronary artery
previously affected
by atherosclerosis.
In most cases,
infarction occurs
when an
atherosclerotic
plaque fissures,
ruptures, or
ulcerates.

CLASSIFICATION

ACS describe a group of conditions resulting from acute myocardial

ischemia (insufficient blood flow to heart muscle) ranging from
unstable angina to myocardial infarction.

RISK FACTORS
Non- Modifiable
Gender and Age
Men, increased risk after age

Modifiable
Smoking
Hypertension

45
Women, increased risk after
age 55
Family History

Diabetis Mellitus
Dyslipidemia
Obesity

Heart disease diagnosed

before age 55 in father or
brother

Lack of physical
activity

WHO Diagnostic Criteria

1.
2.
3.

Clinical history of ischaemic type

chest pain lasting >20 minutes
Changes in serial ECG tracings
Rise and fall of serum cardiac
biomarkers such as creatinine
kinase-MB fraction and troponin

CLINICAL FEATURES
1. Chest pain, >30 minutes
2. Usually tight, crushing, and
band like
3. Location in retrosternal
4. May radiate to left arm, throat,
and jaw
5. Associated features including
palpitation, sweating,
breathlessness, and nausea.

ECG CHANGES IN AMI

ST
segment
elevation
over
area of damage
ST depression in
leads
opposite
infarction
Pathological
Q
waves
Reduced R waves
Inverted T waves

Diagnosis
Signs of myocardial
ischemia
ECG
Yes

ST segmen elevation ?
No

Acute Myocardial
Infarction
(STEMI)

Lab
Yes

Biochemical cardiac markers ?

NSTEMI
( Non ST-Elevation
Myocardial Infarction )

No

Unstable
Angina

Complication

Congestive heart failure

Myocardial rupture

Arrhythmia

Cardiogenic shock

Pericarditis

Therapy
Managing chest pain and anxiety
o Bed rest
o Diet
o O2 2-4 lpm
o Nitrate sublingual/oral/IV
o Antiplatelet: aspirin and clopidogrel
o Morphine/ pethidine
Stabilizing hemodynamic
(blood pressure and peripheral pulse control)
o -blocker
o Calcium channel blocker (CCB)
o ACE-Inhibitor
Reperfusion of the myocardium
o Thrombolytic

TIMI PROGNOSIS IN STEMI

Risk Factor
Age > 65 years old

Score
2

Age > 75 years old

History of
angina/hypertension/DM

1/1/1

Systolic BP <100

Heart rate > 100

Killip II-IV
Weight > 67kg
Anterior MI or LBBB

2
2
1
1

Delay treatment
>4hours

Total Score
0
1
2
3
4
5
6
7
8
9-16

Risk of Death in 30
days
0.8%
1.6%
2.2%
4.4%
7.3%
12.4%
16.1%
23.4%
26.8%
35.9%

PROGNOSIS KILLIP
CLASSIFICATION
Mortality Rate (%)
Class
Description
6
I
no clinical signs of heart
failure
II
rales or crackles in the
17
lungs, an S3, and elevated
jugular venous pressure

III
IV

acute pulmonary edema

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

30 - 40
60 80

Thank You