Faculty of Medicine
Hasanuddin University
Case Report
2016
STEMI
Warren Lie
C11112007
Supervisor:
dr. Pendrik Tandean, Sp.PD-KKV, FINASIM
PATIENT IDENTITY
Name
: Mr SD
Age
: 43 y, 2 mo, 27d
Sex
: Male
ID
: 751291
Date of admission : 27 MAR 2016
HISTORY
Chief complaint: chest pain
Further anamnesis:
First time felt 3 days ago intermittently with
duration of + 15 minutes, resolve with rest.
Squeezing and crushing in quality, radiates to
both arms, back, and left jaw. Eight hours before
admission pain becomes persistent. NPRS 9.
Diaphoresis (+), nausea(+), vomiting (-),
fever(-), dyspnea (+), urination and defecation
normal.
Pain on both legs (+).
HISTORY
Past Medical History:
No known history of hypertension
No known history of DM
History of dyslipidemia (hypercholesterolemia)
No history of heart disease or stroke
History of gout arthritis
No history of cigarette smoking
No family history of heart disease or stroke
PHYSICAL EXAMINATION
General condition:
moderate illness/ normal weight/ conscious
BW: 53 kg, BH: 160 cm, BMI: 20.5 kg/m2
Vital Sign
BP: 100/70 mmHg
R : 20x/min
HR: 80x/min, regular
T : 36.5 oC
Head: pupil round equal size 2.5mm anemia (-),
jaundice (-),
cyanosis (-)
Neck: JVP R+2 cmH20 (30o)
PHYSICAL EXAMINATION
CHEST EXAMINATION
Inspection : symmetrical, no scar, ictus cordis
not visible
Palpation : no mass/tenderness, apex not
palpable
Percussion : normal heart size, liver border ICS 6
Auscultation :
Lung : vesicular breath sound
Rh -/+ (basal) Wh -/Heart : S1 S2 regular, murmur (-)
PHYSICAL EXAMINATION
ABDOMINAL EXAMINATION
Inspection : Flat, follow breath movement
Auscultation : Peristaltic sound (+), normal
Palpation : No mass/tenderness, Liver and spleen are
palpable
Percussion : Tympani (+), no ascites
EXTREMITIES
not
ELECTROCARDIOGRAM
ECG Interpretation
Lab Findings
PARAMETER
RESULT
NORMAL
VALUE
UNIT
WBC
12.42
4.0 10.0
10^3 u/L
Neutrophil
76.5
52.0 75.0
RBC
5.10
4.0 6.0
10^6 u/L
HGB
13.6
13.0 17.0
g/dL
HCT
43.0
40.0 54.0
PLT
321
150 - 500
10^3 u/L
Ureum
29
10 - 50
mg/dL
Creatinine
1.07
<1,3
mg/dL
SGOT
231
<38
U/L
SGPT
48
<41
U/L
Glucose
111
<140
mg/dL
CK
3743
<190
U/L
CK-MB
211.6
<25
U/L
Troponin I
>10.0
<0.01
ng/mL
Sodium
146
136-145
mmol/L
Potassium
4.1
3.5-5.1
mmol/L
Chloride
113
97-111
mmol/L
Therapy
Oxygen 2-4 L/min
NaCl 0.9% 500cc/24h/IV
Thrombolysis:
Alteplase bolus 15mg followed by 50mg IV (30 min) and 35mg IV (1 hour)
Antithrombotic:
Aspirin 80mg/24h/oral
Clopidogrel 75mg/24h/oral
Fondaparinux 2.5mg/24h/SC
Diuretic: furosemid 40mg/12h/oral
HMG-CoA reductase inhibitor: atorvastatin 40mg/24h/oral
ACE-inhibitor: captopril 12.5mg/8h/oral
Nitrates: ISDN 1 mg/1h/SL
Sedative: alprazolam 0.5mg/24h/oral
GOUT: colchicine 0.5mg/24h/oral
Planning
Echocardiography
Angiography
Risk factor management
STEMI
DISCUSSION
ACUTE CORONARY
SYNDROME
Acute coronary
syndrome (ACS) refers
to a spectrum of
clinical presentations
ranging from those for
ST-segment
elevation myocardial
infarction (STEMI)
nonST-segment
elevation myocardial
infarction (NSTEMI)
unstable angina
pectoris
Acute Coronary
Syndrome
ETIOLOGY
Mechanism:
Coronary plaque rupture (95%)
lead to partial or total coronary occlusion
Coronary spasm
Prinzmetal angina (transient ST elevation)
Myocardial infarction (if the ischemic period is too
long)
Coronary embolism
ACUTE CORONARY
SYNDROME
UA/NSTEMI
Non-occlusive
thrombus
No ST segment
elevation as
transmural infarction is
not seen
NSTEMI vs unstable
angina pectoris
cardiac enzyme
STEMI
Occlusive thrombus
Entire thickness of the
myocardium has
undergone necrosis,
resulting in STsegment elevation
RISK FACTOR
NON- MODIFIABLE
Gender
Men > women
Age
Men, increased risk after age 55
Women, increased risk after
age 65
Family History
MODIFIABLE
Hypertension
Diabetes Mellitus
Dyslipidemia
Obesity
Lack of physical
activity
Diet (high fat and
high carbohydrate)
Cigarette Smoking
Stress
PATOPHYSIOLOGY
Plaque
disruption
Platelet
GP IIb/IIIa
Coagulatio
n cascade
Agonist
(collagen,
ADP,
epinephrine
)
TX A2
DIAGNOSIS
Chest pain
Sympto
m
Workin
g
diagnos
is
Acute
coronary
syndrome
Non ST
elevation
ST
elevation
ECG
Biomarker
Biochemist
ry
Final
diagnos
is
(+)
STEMI
Non STEMI
(-)
Unstable
angina
Substernal chest
pain / chest
discomfort
radiated to the
left arm,
shoulder, neck,
jaw
Clinica
l
featur
es
Duration of
chest pain
> 20
minutes
Not fully
relieved by rest
or
nitroglycerine
WORKING DIAGNOSIS
(ACS )
Ischemic symptoms
Prolonged chest pain (usually >20 mins) constricting,
crushing, squeezing. Usually retrosternal, radiating to left
chest, left arm, can be epigastric
Dyspnea
Diaphoresis
Palpitations
Nausea/vomiting
Light headedness
Autonomic nervous system hyperactivity
Rise of serum
cardiac
biomarkers
Characteri
stic
symptoms
WHO
Diagnos
tic
Criteria
Changes in
serial ECG
tracings
HOW TO DIAGNOSE?
ECG
STEMI
NSTEMI
Complete Evolution
Specific ST-Elevation
T inversion
Pathologic Q
Old Infarct
Pathologic Q
ST segment isoelectric
T normal or inverted
Location AMI
ECG
Anterior
Anteroseptal
Anterolateral
Lateral
Inferolateral
Inferior
Inferoseptal
True posterior
BIOMARKERS
BIOMARKERS
Biochemical marker for detection of myocardial
necrosis
Normal value
First rise
after AMI
Peak after
AMI
Return to
normal
CK-MB
4h
24 h
72 h
Myoglobin
< 82 ng/ml
2h
6-8 h
24 h
4h
24 - 48 h
5 21
days
3-4 h
24 36 h
5 14
days
Troponin T Negative
Troponin I
Therapy
Oxygen
Control of Discomfort
Nitrates
Morphine 2-4mg/5mins/IV
Beta-blocker
Limitation of Infarct Size
Primary PCI
Fibrinolysis
Sedation
Antithrombotic
RAAS inhibitor
M
O
N
A
B
A
H
TREATMENT
PROGNOSIS
KILLIP CLASSIFICATION
Class
Description
II
III
IV
17
30 - 40
60 80
30D*
0
0.1 (0.1-0.2)
1
0.3 (0.2-0.3)
2
0.4 (0.3-0.5)
3
0.7 (0.6-0.9)
4
1.2 (1.0-1.5)
5
2.2 (1.9-2.6)
6
3.0 (2.5-3.6)
7
4.8 (3.8-6.1)
8
5.8 (4.2-7.8)
>8
8.8 (6.3-12)
* referenced to average mortality
(95% confidence intervals)
DM, diabetes mellitus; HTN, hypertension; SBP, systolic blood pressure; HR,
heart rate; STE, ST elevation; LBBB, left bundle branch block; and rx, treatment.
COMPLICATION
Ventricular dysfunction
Congestive heart failure
Cardiogenic shock
Arrhythmia
Thromboembolism
LV aneurysm/rupture