Presented by: Rezky F Saban (C11110103)

Supervisor:Dr.dr. Idar Mappangara, Sp.PD,SpJP,FIHA,FINASIM.

CARDIOLOGY DEPARTMENTMEDICAL FACULTY OF HASANUDDIN UNIVERSITY

MAKASSAR 2015

ST ELEVATION MYOCARDIAL INFARCTION

PATIENT IDENTITY

Name : Mr. H

Age : 54 years old

Gender : Male

Address : Kutulu

MR : 698129

Date of Admission : January 22th 2015

HISTORY TAKING Chief Complaint : Chest Pain

Present Illnes History :

It was felt since 4 hours ago before he was admitted to the hospital. The pain felt like compress pain by weight thing, continous,not radiating and along with cold sweating.No dispnea,no dispnea on exertion,no orthopnea,no paroxysmal nocturnal dispnea, no cough,no fever,no nausea,no epigastric pain.Defecation and urination within normal limit.

PREVIOUS ILLNESS HISTORY

• No history of diabetes Mellitus• Nohistory of hypertension• No history of previous chest pain• No history of heart disease at the past

• No history of heart disease in the family•No history of drinking alcohol•No history of smoking

RISK FACTORS

Modified Non-modified

•Gender : Male•Age: 66 years old

PHYSICAL EXAMINATION

General Status• Moderate illness/ Well nourished/ Compos mentis• Nutritional Status:

• Weight : 70 kg • Height : 170 cm • BMI : 24,22 kg/m2 (overweight)

Vital Sign • Blood Pressure : 110/60 mmHg • Pulse Rate : 71 bpm • Respiratory Rate : 22 bpm • Temperature : 36.5 0C (axilla)

Head and Neck Examination • Eye : Conjunctiva anemic (-/-),

Sclera icteric (-/-) • Lip : Cyanosis (-) • Neck : JVP R+1 cmH20

Thorax Examination• Inspection : Symmetric between left and right chest. • Palpation : No mass, no tenderness. • Percussion : Sonor between left and right chest, lung-liver

border in ICS VI right anterior. • Auscultation: Respiratory sound: Vesicular Additional sound : Ronchi -/- , Wheezing -/-

Heart examination :• Inspection : Apex invisible• Palpation : Apex impalpable• Percussion :

Upper heart : ICS II parasternalis linea sinistra

Bottom heart : ICS V parasternalis linea dextra

Left Heart : ICS V midclavicularis linea sinistra

Right heart : ICS IV parasternalis linea dextra • Auscultation : heart sounds I/II regular, murmur (-), gallop (-)

Abdomen Examination :• Inspection : flat, following breath movement • Auscultation : peristaltic sound (+), normal • Palpation : mass (-), pain (-), liver and lien impalpable • Percussion : tymphani (+), ascites (-)

Extremities Examination :• Oedema Pretibial -/-• Oedema dorsum pedis -/-

LABORATORY FINDING January 22th 2015 (1st day of treatment)

TEST RESULT NORMAL VALUE

GDS 160 mg/Dl <140

SGOT 29 u/L <38

SGPT 29 u/L <41

Ureum 35 10-50

Kreatinin 0,90 0,5-1,2

LABORATORY FINDING January 22th 2015 (1st day of treatment)

TEST RESULT NORMAL VALUE

Troponin I 0.12 <0,01

CK 129 <190

CKMB 27.3 <25

Natrium 139 136 - 145

Kalium 4,7 3,5 - 5,1

Klorida 106 97 - 111

Asam Urat 8.8 3,4-7,0

ELECTROCARDIOGRAM

ECG INTERPRETATION• Interpretasi• Ritme : Sinus Rhytm• Heart Rate : 83 bpm• Axis : Normoaxis• P wave : 0,08s• PR Interval : 0,20s• QRS complex : 0,10s, • ST Segment : ST Elevation pada lead II, III, aVF• Conclusion : ST-Elevation Myocardial Infarction

Inferior• Conclusion : Sinus Rythm, HR 83 bpm, ST-Elevation

Myocardial Infarction Inferior

DIAGNOSIS

• Inferior STEMI Onset 4 Hours KILLIP I

MANAGEMENT

• O2 4 lpm via nasal canule

• IVFD NacL 0,9 % 500 cc/24 hours• Actilyse 1 vial/syringe pump (15 mg over in 15 minute,

continue 35 mg over in 45 minute)• Aspilet 80mg/ 24 hours/ oral• Clopidogrel 75mg/ 24 hours/ oral• Atorvastatin 40mg/ 24 hours/ oral• Farsorbid 10mg/ 8 hours/ oral• Arixtra 2.5mg/ 24 hours/ subcutan• Laxadine 10cc / 24 hours/ oral• Alprazolam 0,5 mg/ 24 hours/ oral

DISCUSSION

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.

ACS describe a group of conditions resulting from acute myocardial

ischemia (insufficient blood flow to heart muscle) ranging from

unstable angina to myocardial infarction.

CLASSIFICATION

Diagnosis of ACS

1. Ischemic symptoms

2. Diagnostic ECG changes

3. Serum cardiac marker elevations

At least 2 of the following :

Difference Between cardiac chest pain and non cardiac chest pain• The classic presenting complaint of cardiac chest pain is

chest discomfort, which patients often describe as substernal ‘‘tightness,’’ ‘‘heaviness,’’ or ‘‘pressure.’’

Gender and Age

Men, increased risk age > 45 years

old

Women, increased risk age > 55

years old

Family History

RISK FACTORS

Non- Modified Modifiable

Smoking

Hypertension

Diabetis Mellitus

Dyslipidemia

Obesity

Lack of physical activity

Sign and Symptoms of Myocardial Infarction

CHANGES IN ECG

ECG FindingsSite of infarction Sign of electrically inert

Myocardium

Anteroseptal V1-V3, sometimes V4

Anterior V2-V4. Late R progression in precordial leads.

Anterolateral V4-V6

Lateral V5-V6

Extensive Anterior V1-V6

High Lateral I, aVL

Inferior II, III, aVF

Inferolateral II, III, aVF and V5-V6

Posterior Initial R in V1, V2. >0.04s. R>S

Cardiac biomarkers

Diagnose

No

Yes

YesNo

NSTEMI(No ST-Segment Elevation

Myocardial Infarction)

Unstable Angina

Signs of myocardial ischemia

ST segmen elevation ?

Biochemical cardiac markers ?

ECG

Lab

STEMIAcute Myocardial Infarction

( Q-wave, non-Q wave )

TREATMENT

Prognosis

KILLIP CLASSIFICATION

Class

Description Mortality Rate (%)

I no clinical signs of heart failure 6

II rales or crackles in the lungs, an S3, and elevated jugular venous pressure

17

III acute pulmonary edema 30 - 40

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

60 – 80

TIMI PROGNOSIS

Risk Factor Score

Age > 65 years old  >/= 75

23

History of angina/hipertension/DM

1

Systolic BP <100 3

Heart rate >100 2

Killip II-IV 2

Weight >67 kg 1

Anterior MI or LBBB 1

Delay treatment >4 hours 1

Total Score

Risk of Death in 30

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%

THANK YOU