CARDIOLOGY DEPARTMENT

ANTEROSEPTAL WALL
STEMI WITH ONSET 12
HOURS KILLIP II
Presented by:
Muhamad Faiz bin Mohd Nazri

C11110867

Supervisor:
dr. Abdul Hakim Alkatiri, SpJP .FIHA
CARDIOLOGY DEPARTMENT
MEDICAL FACULTY
MAKASSAR
2015

PATIENTS IDENTITY
NAME
: Mrs. SP
AGE
: 67 years old
GENDER : Female
MR
: 70-74-45
Day of Admission : April 8th, 2015

HISTORY TAKING
CHIEF COMPLAINT: Chest pain
Structural Anamnesis:
It was felt 1 day (onset 12 hours since 9 pm) before
admitted to the hospital. The pain was felt on the left
side of the chest with the characteristics of dull heavy
feeling of the chest, duration of pain was > 30
minutes, radiated to the left arm and to the back. The
pain exacerbated with exercises and did not lessen
with rest or medication. Chest pain accompanied by
shortness of breath. Dyspnea on effort (+) Orthopnea
(-) Paroxysmal Nocturnal Dyspnea (-) Patient usually
slept with 1-2 pillows. Cough (-) Fever (-) Nausea (+)
Vomit (+) Palpitation (-) Cold sweats (+)

PAST MEDICAL HISTORY

History of diabetes melitus (-)
History of hypertension (+) since 1 year ago with
uncontrolled therapy.
History of smoking (-)
History of cardiovascular disease in family (-)

RISK FACTORS
Cigarette smoking (-)
Alcohol consumption(-)
Hypertension(+)
Diabetes (-)
History of Cardiovascular disease (-)
Thyroid disease (-)
History of cardiovascular disease and
thyroid disease in family (-)

PHYSICAL EXAMINATION
General Status:
Moderate illness/ Well nourished/ Conscious
Nutritional Status: Normal (BMI: kg/m)
Weight : 60 kg
Height : 160 cm

Vital Signs:
Blood Pressure
Pulse Rate
Respiratory Rate
Temperature

BMI: 23.4 kg/m2

: 170/110 mmHg
: 68 tpm
: 20 tpm
: 36.7 0C

Head and Neck Examinations:

Eye
: Conjunctiva: anemic (-/-), Sclera: icteric (-/-)
Lip
: Cyanosis (-)
Neck : JVP R +2 cmHO
Chest Examination
Inspection
: Symmetric between left and right
chest.
Palpation
: No mass, no tenderness.
Percussion
: Sonor between left and right chest,
lungliver border in ICS IV right anterior .
Auscultation : Respiratory sound: Vesicular
Additional sound: Ronchi +/
+,Wheezing -/-

Cardiac Examination
Inspection
Palpation
Percussion

: invisible heart apex

: Heart apex was not palpable
: Right heart border in right
parasternal line, one finger lateral from
left medioclavicular line
Auscultation : Heart Sounds : S I/II regular,
murmur (-) gallop(-)

Abdominal Examination
Inspection
: Flat, following breath
movement
Auscultation : Peristaltic sound (+), normal
Palpation
: No mass, no tenderness, no
palpable liver or spleen.
Percussion
: Tympani (+)

Extremities Examination
Pretibial edema -/ Dorsal pedis edema -/-

ECG Interpretation

Rhythm
: Sinus Rhythm
HR / QRS rate
: 83 times/min
Axis
: Normal
Regularity : Regular
P wave
: 0,08 s
PR interval : 0,2s
QRS complex
: 0,16 s
ST segment
: ST elevation at V1-V4
T wave
: T inverted on lead II,III, aVF
Conclusion
: Sinus rhythm, HR 83 times/min,
normoaxis, anteroseptal infarction and ishemic pada
inferior

LABORATORY FINDINGS
(07/04/2015)
COMPLETE BLOOD
COUNT
Test

Result

Normal value

WBC

4.20 x 103/ul

4.0 10.0 x 103

RBC

4.06 x 106/l

4.0 6.0 x 106

HGB

11.2 gr/dl

12 16

HCT

34.4 %

37 48

PLT

209 x 103 /l

150 400 x 103

LABORATORY FINDINGS
(07/04/2015)
BLOOD CHEMISTRY
Test

Result

Normal value

GDS

124 mg/dl

<140

Ureum

33 mg/dl

10 50

Creatinine

0,9 mgr/dl

SGOT

184 u/l

<38

SGPT

27 u/l

<41

Total Chol
HDL Chol

278mg/dl
48 mg/dl

<200
> 55

TG

66 mg/dl

<200

< 1.3

LABORATORY FINDINGS
(07/04/2015)
CARDIAC ENZYMES
Test

Result

Normal value

CK

733.00U/L

<167

CK-MB

65 U/L

<25

Troponin-T

>2,0

<0.05

CHEST X-RAYS 07/04/2015

Conclusion:
Cardiomegaly
Dilatation and elongation of
aorta.

WORKING DIAGNOSIS

ANTEROSEPTAL WALL
STEMI WITH ONSET 12
HOURS KILLIP II

MANAGEMENT

O2 2 -4 Lpm
IVFD NaCl 0,9% 500cc/day
Cedocard 1 mg/hour/SP Nitrat
Arixtra 2,5 mg/24 hour/sc LMWH (Low Molecule
Weight Heparin)
Aspilet 80 mg 0-0-1
Aspirin (Antiplatelet)
Clopidogrel 75 mg 0-0-1
Clopidogrel
(Antiplatelet)
Captopril 6.25 mg 1-1-1 ACE-Inhibitor
Simvastatin 40 mg 0-0-1 Statin (Anticholesterol)

Laxadyn syr 0-0-2c Laxative

Alprazolam 0,5 mg 0-0-1 Antianxietas
Fluid balance

PLANNING
ECG per day

Discussion
STELEVATIONMYOCARDIAL
INFARCTION

INTRODUCTION
Myocardial ischemia is caused by imbalance
between myocardial oxygen supply and
myocardial oxygen consumption.
Myocardial infarction (MI) is the rapid
development of myocardial necrosis.
An acute myocardial infarction is caused by
necrosis (irreversible) of myocardial tissue due to
ischemia, usually due to blockage of a coronary
artery by a thrombus.

European Heart Journal. Guidelines on the management of stable angina pectoris

Regions of the Myocardium

Lateral
I, AVL,V5-V6

Inferior
II, III, aVF

Anterior / Septal
V1-V4

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.

CLASSIFICATION

ACS describe a group of conditions resulting from acute myocardial

ischemia (insufficient blood flow to heart muscle) ranging from
unstable angina to myocardial infarction.

DIAGNOSIS

Oxford Handbook of Clinical Medicine 6th Edition

CARDIAC BIOMAKERS

RISK FACTORS

Modifiable:

Hypertension
Diabetes Mellitus
Dyslipidemia
Smoking
Obesity

Non-modifiable:

Gender: male
Age >45 years old
Personal history of
Coronary Artery
Disease
Family history of
Coronary Artery
Disease

Ischemic symptoms
Prolonged pain (usually >20 mins) constricting, crushing,
squeezing
Usually retrosternal location, radiating to left chest, left arm; can
be
epigastric
Dyspnea
Diaphoresis
Palpitations
Nausea/vomiting
Light headedness
Sense of impending doom

DIAGNOSE????
Signs of myocardial
ischemia
ECG
ST segment
elevation?
No

Yes
ST-elevation Myocardial Infarction

Lab

Biochemical
cardiac markers ?

Yes

NSTEMI
( Non ST-Elevation
Myocardial Infarction )

No

Unstable Angina

KILLIP
CLASSIFICATION

Class

Description

Mortality Rate
(%)

no clinical signs of heart failure

II

rales or crackles in the lungs, an

S3, and elevated jugular venous
pressure

III

acute pulmonary edema

30 - 40

IV

cardiogenic shock or hypotension

(systolic BP < 90 mmHg), and
evidence of peripheral
vasoconstriction

60 80

17

Relieve pain
Hemodinamic stabilitation
Miokardial reperfusion
Prevent the complication

Kabo P. Bagaimana menggunakan obat-obat kardiovaskular secara rasional. 2010

THERAPY
Managing chest pain and anxiety
oBed rest
oDiet
oO2 2-4 lpm
oNitrate sublingual/oral/IV
oAntiplatelet: aspirin and clopidogrel
oMorphine/ pethidine
Stabilizing hemodynamic (blood pressure and peripheral
pulse control)
o-blocker
oCalcium channel blocker (CCB)
oACE-Inhibitor
Reperfusion of the myocardium
oThrombolytic

COMPLICATION of
MYOCARDIAL INFARCTION