PRESENTED BY FITRIYA SYAIFUDDIN.

- C 111 08 230

SUPERVISED BY : Prof. Dr. dr. ALI ASPAR MAPPAHYA,

Sp.PD, Sp.JP (K) .FIHA. FINASIM

Department of Cardiology and Vascular Medicine

Medical Faculty of Hasanuddin University
Makassar
2014
 ID Number : 692281
Name : MR Y
Age : 49 years old
Gender : Male
Date of Admission : Desember 2014
Chief complaint : Chest pain
History of present illness
It felt since 1 day before admission the hospital,
suddenly when he was doing activity. Described as
compressed pain and radiating to the back. duration
more than 20 minutes, The pain didnt relieved by rest
Cold sweating (+), Dispneu (-), DOE (-), PND (-),
Ortopneu (-), Nausea (-), Vomiting (-).

Defecation and urination were normal

HISTORY OF DISEASE
# Past Ilness history
No History of Hypertension
No History of DM
No History of high blood cholesterol
No History of previous heart disease

# Family history
No family history of heart disease

# Personal history:
History of smoking 1 pack each day for more
30 years.
No history of drinking alcohol
RISK FACTOR

Non
Modifiable Modifiable

- Gender : male
- Smoking
General status
Moderate
illness/well
nourished/compos
mentis
Vital sign
BP: 120 / 90 mmHg
HR: 80 x/min
RR: 20 x/min
T : 36.70 C
 Head Examination
Eyes : anemia (-), icterus (-)
Lip : cyanosis (-)
Neck : lymphadenopathy (-), JVP R+2 cmH2O

Thoracal Examination
Inspection : symetric, normochest
Palpation : mass (-), tenderness (-), VF R=L
Percussion : sonor
Auscultation : breath sound :
bronchovesicular,
there are minimally ronchi in a basal lung,
wheezing -/-
 Heart Examination
Abdominal Examination
Inspection : IC wasnt
Inspection : flat and
visible
following breath
Palpation : IC wasnt
movement
palpable
Auscultation :
Percussion : normal heart
peristaltic sound (+) ,
size
normal
Upper border: left 2nd ICS
Palpation : liver and
Lower border : left 5th
spleen unpalpable
ICS
Percussion : tympani,
Right border : right
ascites (-)
parasternalis line
Left border : left axillaris
Extremities
anterior line
Oedema : pretibial (-),
Auscultation : Regular of I/II
dorsum pedis (-)
heart sound, murmur (-)
Sinus rhythm
Heart rate : 88 bpm
Axis : Right Axis
Deviation
P Wave : 0,1 s
PR interval : 0,16 s
Duration QRS : 0,12 s
QS, Q patologis on
lead I, aVL
ST segment :
ST elevation on lead V2,
V3, V4, V5, V6

Conclusion :
Sinus rhythm, HR 88 bpm,
RAD, Extensive anterior
myocard infarction.
 RBG : 179
WBC : 10.3 x 103 mg/dl
HGB : 14.6 g/dl
PLT : 236 x 103 /mm3
GOT : 381 u/l

Blood chemistry
Cardiac enzyme GPT : 89 u/l
Complete blood

CK : 5049 u/L Ureum : 18

CK MB : 349u/L
Troponin T : >2.0 u/L Creatinin : 1.0
Electrolyte
PT : 11.2
Sodium :139 mmol/l
Potassium : 4.0 mmol/l APTT : 31.6
Chloride :105 mmol/l INR :0,91
Uric acid: 5.3
 ECG everyday
Echocardiography
Ro Thorax
Coronary
Angiography
 WORKING DIAGNOSIS
ST Elevation Myocardial Infarction
(STEMI) extensive anterior wall onset
>24 hours Killip I
 O2 2 LPM (via nasal canule)
Cardiac Diet
IVFD NaCl 0,9% 500 cc/24 hours
Anti-Platelet Agregation
Aspilet 160 mg (loading dose), maintenance 80 mg/24 hours/oral
Clopidogrel 300 mg(loading dose), maintenance 75 mg/24 hours/oral
Anti-coagulant
Fondaparinux 2,5mg/24 hours/subcutan
Nitrat
ISDN 5 mg/sublingual (if chest pain occurs)
Farsorbid 1 mg/hour/syringe pump
Anti Hypertension
ACE-I (Captopril) 6,25 mg/8 hours/oral
Laksative
Laxadin syrup 15 ml/24 hours/oral
Anti-anxiety
Alprazolam 0,5 mg/24 hours/oral
DISCUSSION
Acute Coronary Syndrome
(ACS) is a term for situations
where the blood supplied to
the heart muscle is suddenly
STEMI is a clinical
blocked.
syndrome defined by
Describe a group of characteristic symptoms
conditions resulting from of myocardial ischemia in
acute myocardial ischemia association with persistent
(insufficient blood flow to electrocardiographic
heart muscle) (ECG) ST elevation and
Ranging from unstable subsequent release of
angina (increasing, biomarkers of myocardial
unpredictable chest pain) necrosis.
to myocardial infarction
(heart attack).
 Lateral
I, aVL,V5-V6

Inferior
II, III, aVF Anterior / Septal
V1-V4
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
 At least 2 of the following:

1. Ischemic symptoms

2. Diagnostic ECG changes

3. Serum cardiac marker elevations

Deep and visceral chest pain > 20 minutes, similar to
discomfort of angina pectoris but commonly occurs at rest,
more severe, and lasts longer.
Feels squeezing," "griplike," "pressurelike," "suffocating"
and "heavy; or just "discomfort" but not pain.
Location in substernal, retrosternal area, radiated to neck,
jaw, shoulder, or ulnar side of the arm
It is often accompanied by weakness, sweating, nausea,
vomiting, anxiety.
Not relieve with rest or nitrat
CHANGES IN ECG
Biochemical marker for detection of myocardial necrosis
Normal value First rise after Peak after Return to
AMI AMI normal
CK-MB < 5.0 ng/ml 4h 24 h 72 h
Myoglobin < 82 ng/ml 2h 6-8 h 24 h
Troponin T Negatif 4h 24 - 48 h 5 21 days
Troponin I Detection 3-4 h 24 36 h 5 14 days
Limit = 0.5
ng/ml
Abnormal >
2.0 ng/ml
Borderline -
Not detected
 Risk factor

Modifiable Non-modifiable
Smoking Gender and age:
Hypertension - male after age 45 y.o
- after age 55 y.o
Obesity
Diabetes Mellitus Family History
Dyslipidemia in first degree
Low HDL < 40 relative > 55 y.o for
Elevated LDL / TG male/ 65 y.o for
Signs of myocardial ischemia

ECG
Yes
ST segmen elevation ? Acute Myocardial Infarction
(STEMI)

No Lab
Yes NSTEMI
Biochemical cardiac markers ? ( Non ST-Elevation
Myocardial Infarction )

No
Unstable Angina
 Fixing the chest pain and fearness
Bed rest
Diet
O2 2-4 lpm via nasal prongs or face
mask
Sublingual/oral/IV nitroglycerine
Antiplatelet: aspirin and clopidogrel
Morfin/petidine
Diazepam 2-5mg/8 hour
 Stabilizing the hemodynamic (blood
pressure and peripheral pulse control)
-blocker
Calcium channel blocker (CCB)
ACE-Inhibitor
Reperfusion of the myocard
Trombolytic
Prevent Complication
Class Description Mortality Rate
(%)
I No clinical signs of heart failure 6
II Rales or crackles in the lungs, an S3, 17
and elevated jugular venous
pressure
III Acute pulmonary edema 30 - 40
IV Cardiogenic shock or hypotension 60 80
(systolic BP < 90 mmHg), and
evidence of peripheral
vasoconstriction
Risk Factor Score Total Risk of Death
Age > 65 years old Score in 30 days
2
Age > 75 years old 0 0.8%
3
1 1.6%
History of
1 2 2.2%
angina/hipertension/DM
Systolic BP <100 3 3 4.4%
Heart rate > 100 2 4 7.3%
Killip II-IV 2 5 12.4%
Weight > 67kg 1 6 16.1%
Anterior MI or LBBB 1 7 23.4%
Delay treatment >4hours 1 8 26.8%
9-14 35.9%
THANK YOU