Case Report

ST Elevation Myocardial
Infarction (STEMI) Extensive
Anterior Onset < 5 Hours KILLIP I

By : Gunawan S Lawrence

Dr. Pendrik Tandean. SpPD, SpJP(K),KKV

Patient Identity

Name : Mrs. SA
Sex
: Female
Age
: 58 years
Addres : Dwi Dharma Village
Job
: Not working
Status : Married
Date Administrated: Nov 28th 2015
MR : 685210
Room: CVCU

HISTORY TAKING

Chief Complain :
Chest Pain

Present
illness
history:
Chest pain was felt since 5 hours ago before

admitted to emergency room wahidin

sudirohusodo hospital. This pain was
suddenly experienced while patient was
resting. The pain was described as a
supressed sensation, it radiated to the left
arm with duration approximately 30 minutes.

Cold Sweat (+) while chest pain occurred

Palpitation (-)
Nausea (-), vomiting (-) , epigastric pain (-)
Short of breathness (-), history of short of
breathness (-)
Cough (-) ,mucus (-)
Dizziness (-), headache (-) .
Urination : normal
Defecation : normal

History of Past Illness

History of chest pain 2 years ago, it relieved by
rest, patient not take any medicine
History of Hypertension (-)
History of Diabetes Mellitus (-)
History of Dyslipidemia (-)
History of Smoking (-)
Family history of heart disease (-)

RISK FACTOR
Modified Risk Factor
Lack Activity
Dyslipidemia

Non-modified risk factor:

Gender : Woman
Age : 58 years

PHYSICAL EXAMINATION
General
appearan
ce

moderate
illness/overweight/conscious

Vital Sign

BP
P
R
T

: 120/80 mmHg
: 75 x/min
: 20 x/min
:36.5oC

Head

Anemi (-) , icterus (-)

Neck

JVP R + 0 cm H20 ( Position 30

degree )

Cont
Chest
Examinat
ion

Cor

I
: symmetric R=L, normochest
P : mass (-), tenderness (-), VF R=L
P : sonor
A : breath sound : bronchovesicular
additional sound : ronchi -/- , wh -/-

I : ictus cordis unseen

P : ictus cordis unpalpable
P : dull, left heart border
left lineaaxillary line ICS V.
A : HS I/II pure regular,
murmur(-)

CONT
Abdomen :
Inspection
: flat and correspond with
breathing movement
Auscultation : peristaltic sound (+) ,
normal
Palpation : liver and spleen unpalpable
Percussion : tympani, ascites (-)

Extremitas :

edem -/ Warm Extremitas

ELECTROCARDIOGRAPHY FINDINGS
ECG
Interpretation
Sinus Rhythm
Heart Rate :60

bpm
P Wave : 0.08
PR interval :
0.16
QRS complex :
0.08, poor R wave
progression
Axis : LAD
ST-elevated : V1V6, aVL
T Wave : T
depression on V1V6, I, aVL

conclusion
Sinus Ritmik, heart rate 60 bpm, LAD, STEMI

Extensive Anterior

Laboratorium Finding
Complete blood count
Test

Result

Normal value

WBC

13,0 x 103/uL

4.0 10.0 x 103

RBC

4,15 x 106/uL

4.0 6.0 x 106

HGB

12,2 g/dL

12 16

HCT

35,7%

37 48

Blood Chemistry
Test

Result

Normal value

GDS

87 mg/dL

<140

Ureum

27 mg/dl

10 50

Creatinine

0,7 mg/dl

< 1.3

SGOT

27 u/l

<38

SGPT

30 u/l

<41

Total Chol
HDL Chol
LDL Chol

260 mg/dl
50 mg/dl
181 mg/dl

<200
> 65
< 130

TG

160 mg/dl

<200

Cardiac Enzymes
Test

Result

Normal value

CK

5849 U/L

<167

CK-MB

635,6 U/L

<25

Troponin-T

>2

< 0,05

Electrolyte
Test

Result

Normal value

Na

143 mmol/l

136-145

3.4 mmol/l

3.5-5.1

Cl

109 mmol/l

97-111

Rontgen Thorax
Interpretation :
Cardiomegaly,
aorta dilatatio.

Echocardiography

Echocardiography Interpretation
LV Dysfuntion sistolic and diastolic
EF 51 %
Akinetic mid anterior and anterolateral.
Hypokinetic mid anteroseptal

Diagnosis
ST Elevation Myocardial
Infarction (STEMI) extensive
anterior onset < 5 Hours,
KILLIP I

Management
PLANNING
Primary Percutaneus Coronary Intervention
THERAPY
Bed rest
Heart Diet 1
O2 2-4 lpm via canula nasal

IVFD NaCl 0,9 % 500 cc/24 hours

ISDN (Fasorbid) 1 mg /hours/ syring pump
Enoxaparin (lovenox) 0,6 cc /12 hours/ subcutan ( After
12 hours finish primary PCI )
Atorvastatin (Lipitor) 40 mg/ 24 hours/ oral
Clopidogrel loading dose 600 mg lanjut 75 mg/24 hours /
oral
Aspilet loading dose 160 mg lanjut 80 mg/ 24 hours/ oral
Laxadyn syrup 10 cc/24 hours/oral

ST elevation Miocardial infarction

Regions of the 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

Unstable
Angina
Non
occlusive
thrombus
Non specific
ECG
Normal
cardiac
enzymes

NSTEMI

Occluding
thrombus
sufficient to cause
tissue damage &
mild
myocardial
necrosis
ST depression +/T wave inversion
on
ECG
Elevated cardiac
enzymes

STEMI
Complete thrombus
occlusion
ST elevations on
ECG or new LBBB
Elevated cardiac
enzymes
More severe
symptoms

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

Pathophysiologi

Pathophysiologi

PATHOPHYSIOLOGY

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

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

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

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

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

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

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

Modifiable
Smoking

Hypertension

Women, increased risk >

Diabetes

age 55

Dyslipidemia

Obesity

Lack of physical

45

Family History
CAD diagnosed before age
55 in father or brother
CAD disease diagnosed
before age 65 in mother or

activity

Mellitus

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

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

DIAGNOSIS OF ACS
At least 2 of the following
Ischemic symptoms

Troponin T

Diagnostic ECG changes

CK-MB

Serum cardiac marker

CK

elevations

Myoglobin

ECG IN AMI

CHANGES IN ECG

MANAGEMENT

TIMI RISK SCORE FOR

STEMI
Risk of
Risk Factor
Age > 65 years old
Age > 75 years old
History of
angina/hipertension/D
M
Systolic BP <100
Heart rate > 100
Killip II-IV
Weight > 67kg
Anterior MI or LBBB
Delay treatment

Score
2
3
1
3
2
2
1
1
1

Total
Death in 30
Score
days
0
0.8%
1
1.6%
2
2.2%
3
4.4%
4
7.3%
5
12.4%
6
16.1%
7
23.4%
8
26.8%
9-14
35.9%

KILLIP CLASSIFICATION
Class
Description
I
no clinical signs of heart
failure
II
rales or crackles in the
lungs, an S3, and
elevated jugular venous
pressure
III
acute pulmonary edema
IV
cardiogenic shock or
hypotension (systolic BP
< 90 mmHg), and
evidence of peripheral
vasoconstriction

Mortality Rate (%)

6

17

30 - 40
60 80

SECONDARY PREVENTIONS FOR

PATIENTS WITH STEMI
Weight management (BMI 18.5 to 24.9 kg per m 2; waist
circumference
less than 40 inches in men, less than 35 inches in women)
Diabetes management (A1C less than 7 percent)
Antiplatelet and anticoagulant therapy
Renin-angiotensin-aldosterone system blocker therapy
Beta blocker therapy

Than
k
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