STEMI WHOLE ANTERIOR ONSET <12 HOURS

KILLIP I
Presented by:
Godeberta Astria Pakan

Supervisor :
dr. Pendrik Tandean, Sp.PD KKV, FINASIM
Department of Cardiology and Vascular Medicine
Medical Faculty of Hasanuddin University
Makassar
2014
PATIENT IDENTITY
Name : Mr. S
Gender : Male
Age : 43 years old
Address : Kerabat Kera-Kera
Registration number : 677672
Date of admission : 27
th
August 2013

ANAMNESIS
Chief Complaint : Chest pain
Present Illness History :
The chest pain began for + 3 hours before he was admitted to
Wahidin Sudirohusodo hospital, occurred when he was working
at office. The pain is described like dull heavy feeling on the
chest, continuously, radiate to back, left and right arms. The
chest pain accompanied with cold sweating a lot and palpitation.
ANAMNESIS

Nausea (-), vomiting (-)
Cough ( - ), Shortness of breath ( - ), Fever (-)
Dyspnea on effort (-), Paroxysmal nocturnal dyspnea(-)
, Orthopnea (-)
Urination normal
Defecation normal

ANAMNESIS
Previous Illness History
History of heart disease ( - )
History of hypertension ( - )
History of diabetes melitus (-)
History of dyslipidemia (-)
ANAMNESIS
Personal History

History of smoking (+) 1 pack/day (stop
smoking + 2 years ago)
History of drinking alcohol 1 bottle/day (stop
drink alcohol + 10 years ago)

PHYSICAL EXAMINATION
General appearance : Moderate illness/pre-obese/
composmentis
Vital Signs:
BP : 150/100 mmHg RR : 20 x/min
HR : 90x/min T : 36,7C
Weight : 82 kg
Height : 170 cm
BMI : 28,4 kg/m
2

Head : Anemia (-) , Icterus (), Palpebra Edema (-)
Neck : JVP R+0 cmH
2
0
Lung : Vesicular Ronchi -/- Wheezing -/-


PHYSICAL EXAMINATION
Cor :I : Punctum Maximum Impulse not visible
P : Ictus cordis not palpable
P : Dull, normal heart size
-Upper border : left 2
nd
ICS
-Right border : right 4
th
ICS parasternalis line
-Left border : left 5
th
ICS medioclavicular line
A : Heart Sound I/II pure regular, murmur(-)

PHYSICAL EXAMINATION
Abdomen :
Inspection : symmetrical big and following breath
movement
Auscultation : peristaltic sound (+) , normal
Palpation : liver and spleen unpalpable, mass (-)
Percussion : tympani, ascites (-)

Extremities : Edema -/-


CHEST X-RAY
Result : There are no
abnormalities in this
x-ray

ECG FINDINGS

Conclusion :
Sinus rhytm HR 75 bpm, normoaxis . ST-elevation on lead V1-V6. Whole anterior
myocardial infarction.




ECG INTERPRETATION
Rhythm : Sinus Rhythm
HR / QRS rate : 75 times/min
Axis : Normoaxis
Regularity : Regular
P wave : 0,1 s
PR interval : 0,20 s
QRS complex : 2 small squares (0,08 s)
ST segment : ST Elevation V1-V6
T wave : normal
Conclusion :
Sinus rhytm HR 75 bpm, normoaxis . ST-elevation
on lead V1-V6. Whole anterior myocardial
infarction.

Complete blood count

RBC : 5,26 x 10/uL
WBC : 11,8 x 10/uL
HGB : 15,8 g/dL
HCT : 45,8 %
PLT 248 x 10/uL
Enzymes
CK : 234 U/L
CKMB : 12.6 U/L
Troponin T : 0.27

Blood chemistry
Ureum : 23 mg/dl
Creatinine : 0.9 mg/dl
SGOT : 25 u/dl
SGPT : 25 u/ dl
GDS : 146 mg / dl
Uric acid : 5.9 mg / dl
Coagulation Time
PT : 10.5s
APTT : 24.2s
LABORATORIUM FINDINGS
DIAGNOSIS
STEMI Whole Anterior Wall onset <12 hours, Killip I
Hypertension Grade I

INITIAL MANAGEMENT
O
2
2-4 liter per minute ( via nasal canule )
IVFD NaCl 0,9% 500cc/24 hours
Isosorbide Dinitrate 5 mg/ sublingual (if there is chest
pain)
Aspilet 160 mg (loading dose)
Clopidogrel 300 mg (loading dose)
Farsorbid 2 mg/hour/Syringe Pump
Captopril 25 mg 1-1-1
Actylise 100 mg (15 mg bolus intravena, 50 mg/30
minutes/SP, 35 mg/60 minutes/SP)

PLANNING
Coronary Angiography

Acute coronary syndromes (ACS) is an term for situations
where the blood supplied to the heart muscle is suddenly
blocked.
describe 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).

STEMI requires evaluation for acute
reperfusion intervention


Silbernagl and Lang Colour Atlas of Phatophysiology. 2000


Stable
Angina
Unstable
Angina
Infraction
Non Modifable
Gender and Age
Men, increased risk
after age 45
Women, increased
risk after age 55
Family History
Heart disease
diagnosed before age 55
in father or brother
Heart disease
diagnosed before age 65
in mother or sister
Modifable
Smoking
Hypertension
Diabetis Mellitus
Dyslipidemia
Obesity
Lack of physical activity

Ischemic
symptoms
Diagnostic
ECG changes
Serum cardiac
marker elevations
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
Troponin T
CK-MB
CK
Myoglobin

CARDIAC BIOMARKERS

TIMI RISK SCORE FOR STEMI
Historical
Age 65-74
>/= 75
2 points
3 points
DM/HTN or Angina 1 point
Exam
SBP < 100 3 points
HR > 100 2 points
Killip II-IV 2 points
Weight < 67 kg 1 point
Presentation
Anterior STE /LBBB 1 point
Time to rx > 4 hrs 1 point
Risk Score = Total (0-14)
RISK SCORE
ODDS OF
DEATH BY
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)

Relieve pain
Hemodynamic stabilization
Myocardial reperfusion
Prevent the complication


1. Bed Rest
2. Diet
3. Oxygen (2-4L/minute)
4. Anti platelet therapy :
Aspirin 162-325mg chewed immediately and 81-162 mg
continued indefinitely.
Clopidogrel 300-600mg loading dose and 75mg daily continued
for at least 14 days and up to 12 months.
5. 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%.




2013 ACC/AHA Guideline STEMI

6. Morphine 2-5mg iv (can be administered again in
5-30 minutes later)
7. Fibrinolytic therapy:
a) Streptokinase 1.5million units iv
b) Tenecteplase 0.5mg/kg body weight iv
8. Anticoagulation therapy:
a) Low Molecular Weight Heparins ( Fondaparinux)
2.5mg/24hrs/sc for up to 8 days post-MI.
9. Anti Hypertension Drugs
10. Lipid Lowering Agents



COMPLICATIONS
Sudden Death
Ventricular Dysfunction
Hemodynamic Disturbances
Cardiogenic shock
Pericarditis
Arrhythmia post STEMI



Class Description Mortality Rate (%)
I No clinical signs of heart failure 6
II
Rales or crackles in the lungs, an S
3
, 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