STEMI

(ST ELEVATION MYOCARDIAL INFARCTION INFERIOR

HOURS ONSET)

+ LATERAL 5

By:
A.YUSRIANA AZZAHRA
SUCIATI
SITI ARIFAH
NURUL INDAH PERTIWI
BESSE JUMRANA
ARMAWATi
SRI MEGAWATI

Supervisor :
DR dr. Idar Mapangara, SpPD, SpJP, FIHA, FICA, FINASIM
DEPARTMENT OF CARDIOLOGY AND VASCULAR MEDICINE
MEDICAL FACULTY OF HASANUDDIN UNIVERSITY
MAKASSAR
2016

PATIENT IDENTITY
Name

: Mr. Y

Age

: 65 years old

Occupation

: retired

Address

: Pondok Asri II Blok E/21

MR

: 755130

Date of Admission

: April 23th 2016

HISTORY TAKING
Chief complaint : Chest pain
Present Illness History :
Left chest pain felt since 5 hours before
admission
Described as pressed pain which radiates to the
back and right arm. Duration of pain is more than
20 minutes. Pain is associated with cold sweating.
Not fully relieved by rest
There is no dyspnea at onset, no fever, no nausea
and no vomiting

HISTORY TAKING
Past history:
There is history of hypertension for 5
years, which is not well controlled
There is no history of chest pain
There is no history of heart disease
There is no history of Diabetes
Mellitus

HISTORY TAKING
Personal Life History :
No history of smoking
No history of alcohol consumption
No history of heart disease in the family
No history of diabetes in the family

Past Treatment History :

No history of hospital admission

Physical Examination
General state:
Moderate Illness/ Well nourished/Composmentis
Body Weight : 70 kg
Body Height : 175 cm
Body Mass Index : 22,8 kg/m2

Vital state
Blood Pressure : 130/80 mmHg
Heart Rate : 80 x/mnt
Respiratory Rate: 18x/mnt
Body Temperature: 36,5 C (axilla)

Physical Examination
Head :Normochepalic
Eye :Anemis (-), Icteric (-)
Pupil :Equal, round, diameter 2,5 mm,
reactive to light
Nares :Appearance is normal
Lip :No cyanosis
Neck :JVP R+2 cmH2O, no
lymphadenopathy, no thyroid
enlargement

Physical
Examination
Chest Examination

Inspection : Symmetrical left = right

Palpation : Mass (-), tenderness (-),
Percussion :Sonor left=right;
Lung-liver border in ICS VI anterior
Auscultation: Breath sound : vesicular
Additional sound : ronchi -/wheezing -/-

PHYSICAL EXAMINATION
Cor :
Inspection : ictus cordis is visible
Palpation : ictus cordis palpable, thrill (-)
Percussion :
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis
dextra
Left border 5th ICS linea axillaris anterior
sinistra
Auscultation : heart sound I/II pure,
regular,
murmur (-)

Physical Examination
Abdominal Examination
Inspection : Convex, following breath movement
Auscultation : Peristaltic sound (+), normal
Palpation : Mass (-), tenderness (-), no palpable
liver and spleen
Percussion : Timpani (+), Ascites (-)

Extremities examination
Pretibial edema -/ Dorsum pedis edema -/-

ELECTROCARDIOGRAPHY
Sinus rhytm
HR : 90 bpm
Regularity:
regular
Axis :
normoaxis
PR interval :
0.12 s
QRS rate : 0.08
s
QRS complex :
normal
ST segmen :
ST segmen
elevation on
lead II,III,aVF,
on lead V5 ,V6
Conclusion :
Sinus rhytm, HR

LABORATORY RESULTS
TEST

RESULT

NORMAL

TEST

RESULT

VALUE

VALUE
WBC
RBC

NORMAL

13.100 x

4.0 10.0 x

Total

200

103/uL

103

4,33

4.0 6.0 x

Cholesterol
HDL

>59

106

LDL

130

Triglyceride

200

Ureum

17

10-50

HGB

12.9

12 16

HCT

36,2

37 48

PLT

295x
103/uL

150 400 x
103

Creatinine

0.69

0,5-1,2

PT

9.9

10 - 14

Troponin I

2,48

<0,01

APTT

25.2

22,0 - 30,0

INR

0.95

CK

523,00

<190

GDS

117mg/dl

140

CK-MB

53.5

<25

GD2P

<200

Natrium

142

136 - 145

Kalium

3,5

3,5 - 5,1

Chloride

111

97 - 111

Uric Acid

3,4-7,0

P
SGOT

60u/L

<38

SGPT

20 u/L

<41

CHEST X-RAY
Result :
Active old
pulmonary
tuberculosis
wide lesion
Left pleural
effusion

DIAGNOSIS
ST ELEVATION MYOCARDIAL
INFARCTION INFERIOR + LATERAL
5 HOURS ONSET

TREATMENT
Oxygen 2-4 liters per minute via nasal
cannule
IVFD NaCl 0,9% 500 cc/24 hours/IV
Nitrate (Cedocard) 1 mg/jam/syringe pump
Aspirin 160mg (loading dose) 80mg/24
hours/oral (maintenance)
Clopidogrel 300mg (loading dose) 75
mg/24 hours/oral (maintenance)
Actilyse (Fibrinolytic) :
15 mg bolus iv
50 mg/syringe pump in 30 minutes
35 mg / syringe pump in 60 minutes
Simvastatin 40 mg/24 hours/oral
Captopril 12,5 mg/8 hours/oral
Bisoprolol 2,5 mg/24 hours/oral

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).

Introduction

PATHOPHYSIOLOGY

American Heart Association: http://watchlearnlive.heart.org

American Heart Association: http://watchlearnlive.heart.org

SYMPTOMS

ECG
ST segment elevation 0,1 mV from
J point on 2 or more pair leads.

RELATION BETWEEN INFARCT LOCATION

WITH Q-WAVE AND ST ELEVATION
Location

Coronary
Arteries

ECG Leads

CARDIAC MARKER

CARDIAC MARKER
Biochemical marker for detection of myocardial
necrosis
First rise
after AMI

Peak after
AMI

Return to
normal

CK-MB

4h

24 h

72 h

Myoglobin

2h

6-8 h

24 h

Troponin T

4h

24 - 48 h

5 21 d

Troponin I

3-4 h

24 36 h

5 14 d

ALGORITMA EVALUASI SKA

MANAGEMENT

INITIAL MANAGEMENT

Evaluate ABC
Bed rest
Oxygen (2-4 lpm via nasal cannule)
Anti platelet therapy :
Aspirin 160-320mg chewed immediately and 80-160 mg
continued indefinitely.
Clopidogrel 300-600mg loading dose and 75mg continued
daily for at least 14 days and up to 12 months.
Nitroglycerin :
0.4 mg SL tablets every 3-5 min up to 3 times; if effect is not
sustained, can continue with an IV drip of 50mg in 250mL
Dextrose 5%.
Morphine 2-5mg iv (can be administered again in 5-30 minutes
later)- if needed

REPERFUSION THERAPY
Fibrinolytic therapy:
Streptokinase 1.5 million units in 100 mL dextrose 5% or NaCl
0,9% finished in 30 60 minutes
Actilyse
:
15 mg bolus iv
0.75mg/kg weight body in 30 minutes
and 0,5 mg/kg weight body in 60 minutes
Anticoagulation therapy ( for STEMI patient with fibrinolytic
therapy, given for 5 days)
Low Molecular Weight Heparins (Enoxaparine) 0.4cc/sc

Unfractionated heparin
Intervention therapy Percutaneous coronary intervention (PCI)
atau CABG in 2 hours

LONG TERM THERAPY

1. Control risk factors, such as hypertension,
diabetes, and tobacco consumption.
2. Antiplatelet therapy with low dose aspirin.
3. Beta-blockers
4. Lipid profile control.
5. High dose statins
6. ACE-I/ARB
7. Aldosteron antagonist

COMPLICATION
Hemodynamic disturbance
Heart failure
Arrhythmia
Cardiac complication
Mitral regurgitation
Heart rupture
Ventricular septum rupture
Right ventricle infarct
Pericarditis
Left ventricle aneurysm
Left ventricle thrombus