CASE REPORT

ST Elevation Myocardial Infarction Extensive

Anterior Onset 1 hour KILLIP I
by :
Dewi Wahyuni Supangat
C 111 08
Supervisor :
Dr. dr. Idar Mapanggara Sp.PD Sp.JP FIHA
Universitas Hasanuddin
2015

Patients Identity

Name
: Mr. A.P
Age
: 60 years old
Address
: AP. Pettarani street
Medical Record
: 577891
Date of admission
: 10th of April 2015

History Taking
Chief complaint : Chest pain
Present Illness History :
Left chest pain felt since 1 hour before admission
Described as a compressed and continuous pain,
radiating to the left arm, intermittently, duration of pain
was over 30 minutes.
Pain worsen by activities and does nt relieve with
resting
Accompanied with sweat
There is dyspnea
No extremity oedem

Past Illness History

Past Illness History :
History of hypertension since 4 years ago, still on
treatment
History of smoking, 1 to 2 packs per day since about 18
years old, but he was quite since 2 years ago
No history of heart attack
No history of chest pain before
No history of Diabetes Mellitus
No history of alcohol consumption

Physical Examination
General Status
Moderate illness / Overweight / Composmentis
Weight

: 70 kg

Height

: 174 cm

BMI

: 23,05 kg/m2

Vital Status
Blood pressure
Heart rate

:140/90 mmHg
: 64 bpm

Respiratory rate
Temperature

: 22 rpm

: 36,7 oC

Physical Examination
Head: anemic (-) icteric (-)
Neck : JVP R+2 cmH2O,
Lung :
Inspection
: symmetry left=right
Palpation
: mass (-), no tenderness, normal
vocal fremity
Percussion
: sonor
Auscultation : vesicular, ronchi -/-, wheezing -/-

Physical Examination
Cor
:
Inspection

: ictus cordis not visible

Palpation : ictus cordis not palpable, thrill (-)

Percussion
:
Upper border on 2nd sinistra ICS
Right border on linea parasternalis dextra 4th ICS
Left border on linea axillaris anterior sinistra 5th
ICS
Auscultation : I/II pure heart sound , regular, murmur
(-)

Physical Examination
Abdomen :
Inspection
: flat, follows breath movement
Auscultation : peristaltic (+), normal
Palpation : liver and spleen not palpable
Percussion : tympani
Extremities

: Edema (-)

Sinus : rhythm
Heart rate :
64bpm
Axis : normoaxis
P Wave
: 0,08
s
PR interval : 0,12
s
Duration QRS
: 0,08 s
ST segment : ST
elevation on lead
1, aVL, V1-V6
ST depresion : II,III,
AVF
Conclusion :
Sinus rhythm, HR
64 bpm,
normoaxis, ST
elevation on lead I,
avL, V1-V6
(Antero-septal
myocard
infarction)

Electrocardiography

Laboratoratory (10th of Mei 2015)

TEST

RESULT

NORMAL VALUE

WBC

12,4x 103/uL

4.0 10.0 x 103

RBC

4,13 x 106/uL

4.0 6.0 x 106

HGB

13,6g/dL

12 18

HCT

39,6%

37 48

PLT

286 x 103/uL

150 400 x 103

PT

10,6 ctrl 11,5

10 - 14

APTT

21,5 ctrl 22,5

22,0 - 30,0

Blood Chemistry
Test

Result

Normal value
33

10-50

1,14

0,5-1,2

SGOT

25 u/L

<38

SGPT

10 u/L

<41

Uric acid

6,6

3,4-7,0

Sodium

145

136 - 145

Potassium

3,5

3,5 - 5,1

Chloride

109

97 - 111

Ureum
Creatinine

Cardiac Enzym Laboratory

Test

Result

Normal value

CK-MB

674

<190

Troponin-T

>2.0

<0.02

Cardiac Enzym Laboratory

Test
CK-MB

Result
90

Normal value
<190

Rontgen
Result :
Cardiomegaly
with aorta
dilatation

Echocardiography
Conclusion:
Disfunction of systolik and diastolic left
ventrikel
Ejection fraction 42 %
Left hypertrophy Ventricle
Mild mitral Regurgitation
Hypokinetic anteroseptal and
anterolateral

Diagnotic
ST Elevasion Myocardiac Infarction
extensive anterior onset 1 hour
KILLIP I

Management
Bed rest
O22-4 liter /minute via nasal canule
IVFD NaCl 0,9 % 500 cc/24 hours
Anti-Platelet Agregation
Aspilet 160 mg (loading dose), maintenance 1x80 mg
tab
Clopidogrel 300 mg(loading dose), maintenance 1x75
mg tab
Nitrat
Cedocard 2mg/hour/syringepump
Anti-coagulant
Lovenox 0,6cc/12hours/subcutaneous
Anti Hypertension/ anti-remodelling
Captopril 6,25 mg/ 8 hours/ oral
Anti inflammation (pleiotropic effect)
Simvastatin 40mg/24hours/oral

Management
Laksative
Laxadyn syrup 10cc/24hours/oral
Anti-anxiety
Alprazolam 0.5mg/24hours/oral
Thrombolytic
Ateplase 15mg/ IV (bolus)
Ateplase 50mg/ IV /SP (30 min)
Ateplase 35mg/ IV/ SP (60 min)

Discussion
Acute Coronary Syndromes(ACS)

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

Classification

Pathophisiology

Clinical Manifestasion

Ischemic symptoms

Prolonged pain over 20 minutes

Described as a dull pain, constricting, crushin or squeezing

Location : retrosternal , radiating to left chest, left arm, or

epigastric area

Dyspnea

Diaphoresis

Palpitations

Nausea/vomiting

Light headedness

Sense of impending doom

Diagnostic
At least 2 of the following :
Ischemic symptoms
Diagnostic ECG changes
Serum cardiac marker elevations ( Troponin T,
CK-MB, CK, Myoglobin)

ECG Changes

Presetation :
Ischemic Chest
Discomfort
Early diagnostic :
ACS
ECG :
No ST Elevation
Normal
Cardiac
Biomake
r

Final diagnostic :
Unstable Angina

ECG :
ST Elevation
Elevated
Cardiac
Biomake
r

Elevate
d
Cardiac
Biomak
er

Final diagnostic :
NSTEMI

Final diagnostic :
STEMI

Management

Risk Factors
Modifiable

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

17

III

Acute pulmonary edema

30-40

IV

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

60-80

Thank You