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STEMI

(ST ELEVATION MYOCARDIAL


INFARCTION)
By:

DEPARTMENT OF CARDIOLOGY AND VASCULAR


MEDICINE
MEDICAL FACULTY OF HASANUDDIN UNIVERSITY
MAKASSAR
2016
PATIENT IDENTITY
 Name : Ms. IT
 Age : 61 years old
 Occupation : Housewife
 Address : Sanrangan Street, Makassar
 MR : 744576
 Date of Admission : February 7th 2016
HISTORY TAKING
 Chief complaint : Chest pain
 Present Illness History :
 Left chest pain felt since 1,5 hours ago before admission
 Described as oppressed pain and felt through the back and
spread to right arm, duration of pain more than 30 minutes.
With cold sweating.
 Not fully relieved by rest
 There is dyspnea, no fever, no nausea and and no vomiting
HISTORY TAKING

Past history:
 history of chest pain on and off since 1 month ago
 History of hypertension since 5 year ago
 History of heart disease is none
 History of Diabetes since 2 years ago
HISTORY TAKING
 Personal Life History :
 There is 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/Conscious
 Body Weight : 70 kg
 Body Height : 175 cm
 Body Mass Index : 22,8 kg/m2

 Vital state
 Blood Pressure : 150/90 mmHg
 Heart Rate : 82 x/mnt
 Respiratory Rate : 24 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
 Lip :No cyanosis
 Neck :JVP R+2 CmH2O, no lymphadenopathy, no
thyroid enlargement
Physical Examination
 Chest Examination
 Inspection : Symmetry 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 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 : 70 bpm
Regularity: iregular
Axis : normoaxis
PR interval : 0.16 s
QRS rate : 0.08 s
QRS complex : VES
trigemini
ST segmen :
ST segmen elevation
on lead II,III,aVF

Conclusion :
Sinus rhytm, HR : 70
bpm, inferior walls
myocardial infarction,
VES trigemini
LABORATORY RESULTS
TEST RESULT NORMAL TEST RESULT NORMAL

VALUE VALUE

WBC 7.800 x 4.0 – 10.0 x 103 Tot.Choles - 200


103/uL HDL - >59
RBC 3,85 4.0 – 6.0 x 106
LDL - 130

13.4 Trigliserida - 200


HGB 12 – 16
HCT 39 37 – 48 Ureum 25 10-50

PLT 277x 103/uL 150 – 400 x 103 Kreatinin 072 0,5-1,2

Troponin I <0.01 <0,01


PT 11.6 10 - 14
CK 154,00 <190
APTT 26.4 22,0 - 30,0
1.12 CKMB 12.3 <25
INR
GDS 173mg/dl 140 Natrium 143 136 - 145

GD2PP - <200 Kalium 3,8 3,5 - 5,1

Klorida 107 97 - 111


SGOT 22 u/L <38
Asam Urat - 3,4-7,0
SGPT 20 u/L <41
CHEST X-RAY

Result :
• Slight Cardiomegaly
with dilatation of
aortae
• Normal Pulmo
DIAGNOSIS
 STEMI inferior onset <6 hours, KILLIP I
 Hipertension gr.I
 Diabetes Melitus Type 2
TREATMENT
 Oxygen 2-4 liters per minute via nasal kanula
 IVFD NaCl 0,9% 500 cc/24 hours/IV
 Aspirin 160mg (loading dose) 80mg/24 hours/oral
 Clopidogrel 300mg (loading dose) 75 mg/24 hours/oral
 Actilyse : 15 mg bolus iv
50 mg/syringepump in 30 minutes
35 mg / syringepump in 60 minutes
 Simvastatin 40 mg/24 hours/oral
 Alprazolam 0,5mg/24 hours/oral
 Laxadyne syr 10 cc/24 hours/oral
 Lovenox 60 mg/12 jam/subcutan
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
RISK FACTORS

Modifiable Non-Modifiable
Smoking Gender & Age
Hypertension • Men > 45 years old
• Women > 55 years old
Diabetes mellitus
Hypercholesterolemia Family history
Obesity • Heart disease in biological
brother or father > 55 years
Psychosocial stress old
• Heart disease in biological
Lack of physical activity sister or mother > 65 years old
DIAGNOSIS OF ACS

At least 2 of the following

 Ischemic symptoms

 Diagnostic ECG changes  Troponin T

 CK-MB
 Serum cardiac marker
 CK
elevations
 Myoglobin
ISCHEMIC SYPMTOMS
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
 Not fully relieved by rest or nitroglicerine
 Dyspnea
 Diaphoresis
 Palpitations
 Nausea/vomiting
 Light headedness
 Sense of “impending doom”
ECG CHANGES

Hyperacute Phase Complete Evolution Old Infarct


• Non specific ST- • Specific ST-Elevation • Q-Pathologic
Elevation • T inverted • ST segment isoelectric
• T taller and wider • Q-Pathologic • T normal or inverted
Cardiac Biomarker
Biochemical marker for detection of myocardial necrosis

First rise after Peak after AMI Return to


AMI normal
CK-MB 4h 24 h 72 h
Myoglobin 2h 6-8 h 24 h
TroponinT 4h 24 - 48 h 5 – 21 d
Troponin I 3-4 h 24 – 36 h 5 – 14 d
GOAL OF TREATMENT
Initial Treatment
 Bed rest
 Oxygen (2-4 lpm)
 Anti platelet therapy :
 Aspirin 160-320mg chewed immediately and 80-160 mg continued indefinitely.

 Clopidogrel 300-600mg loading dose and 75mg daily continued 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)
 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:
 Low Molecular Weight Heparins (Fluxum) 0.4cc/sc for up to 8 days post-MI.
 Unfractionated heparin

 Anti Hypertension Drugs


 Lipid Lowering Agents
PROGNOSIS
KILLIP CLASSIFICATION
MORTALITY RATE
CLASS DESCRIPTION
(%)

I No clinical signs of heart failure 6

Rales or crackles in the lungs, an S3,


II 17
and elevated jugular venous pressure

III Acute pulmonary edema 30 - 40

Cardiogenic shock or hypotension


IV (systolic BP < 90 mmHg), and 60 – 80
evidence of peripheral vasoconstriction