ST Elevation Myocardial

Infarction (STEMI)
Inferior
By :
Anom Partha Jaya (C11112131)
Supervisor :
dr. Pendrik Tandean, Sp.PD-KKV, FINASIM
Cardiology Department
Medical Faculty of Hasanuddin
University

PATIENTS IDENTITY

Name

: Mr. S

Gender

: Male

Age

: 48 years old

Registration no.

Date of Admission : 11/06/2016

: 760995

History Taking

Chief Complaint:
Chest pain

Guided Anamnesis:
Occured about 6 hours before admitted to the hospital. The chest pain
was felt suddenly during rest. The pain was felt at the left side of the
chest and it feels like compressed pain, radiated to the left arm and also
radiated to the back associated with cold sweat. The duration of the chest
pain occurs about 30 minutes and relieved by the time past. The history
of chest pain before is denied. Short of breathness during laying down is
denied, no history of coughing, fever, nausea and vomiting or epigastric
pain. Defecation and urination are normal.

Past Illness History

History of smoking since 20 years old, 1-2 packs of cigarettes in a day

History of Hypertension, Diabetes Mellitus, Hypercholesterolemia denied

Risk Factors
Non-Modified Risk Factor :
Gender
Age

Modified Risk Factor :

Smoking

Clinical Examination
GENERAL STATE
Moderate illness/ non obese/ compos mentis (GCS E4M6V5)
VITAL SIGN

Blood pressure

: 100/70 mmHg

Pulse

: 80 bpm

Breathing

: 22 times/min

Temperature

: 36,7C (Axilla)

Head Examination

Eyes
: anemic -/-, icterus -/-, cyanosis -/
Neck : tumor mass (-), tenderness (-),
JVP R+3 cmH2O, trachea deviation (-)
Chest Examination

Inspection

Palpation

Percussion

: symmetrical R=L
: mass (-), tenderness (-)
: sonor R=L
lung-hepar border = right ICS IV
Right back lung border = right CV th VIII
Left back lung border = left CV th IX
Auscultation
: breath sound : bronchovesicular
additional sound : ronchi -/- wheezing -/-

Cardiac Examination
Inspection
: heart apex was not visible
Palpation
: heart apex was not palpable
Percussion
: normal heart size
Auscultation
: Regular of I/II heart sound,
murmur (-)

Abdominal Examination

Inspection
: flat and following breath movement
Auscultation : peristaltic sound (+), normal
Palpation
: liver and spleen unpalpable
Percussion
: tympani (+), ascites (-)

Extremities
- Oedema

: pretibial -/-, dorsum pedis -/-

ELECTROCARDIOGRAM

Rhythm
HR
: 83
Regularity
P wave
PR interval
Axis

: sinus rhtym
bpm
: regular
: 0.08 sec
: 0.16 sec
: Normal axis

Duration of QRS
ST segment :

: 0.08 sec

ST elevation in lead II, III, AVF,

V2R-V4R
ST depretion in lead I, AVL,
V1,V2, V3

ELECTROCARDIOGRAM

INTERPRETATION
Rhythm
: sinus rhtym
HR
: 83 bpm
Regularity : regular
P wave
: 0.08 sec
PR interval : 0.16 sec
Axis
: Normal axis

Duration of QRS
ST segment :

: 0.08 sec

ST elevation in lead II, III,

AVF, V2R-V4R
ST depression in lead I,
AVL, V1,V2, V3
T inverted in I, AVL, V2

Conclusion :

Sinus rhtym, HR 83 x/minute, Normal axis, inferior wall

myocardial infarction and Right Ventricle Infark

LABORATORY FINDINGS
TEST

RESULT

NORMAL

TEST

RESULT

NORMAL
VALUE

VALUE
8,6 x 103/uL

4.0 10.0 x

Tot.Choles

196 mg/dl

200

RBC

5.60 x 106/uL

103
4.0 6.0 x 106

HDL

36 mg/dl

>59

HGB

16.2

12 18

LDL

156 mg/dl

<130

HCT

46

37 48

Triglycerides

119 mg/dl

200

PLT

198 x 103/uL

150 400 x

Ureum

15

10-50

1,26

<1,3

PT

10,4

10
10 - 14

Creatinin
Troponin I

1,48

<0,01

APTT

23,1

22,0 - 30,0

CK

392

<190

INR

1,00

CKMB

50,4

<25

Blood

127 mg/dl

< 200

Sodium

141

136 - 145

Glucose

140

SGOT

106
40 u/L

<38

potassium

4,1

3,5 - 5,1

SGPT

17 u/L

<41

chloride

113

97 - 111

Uric acid

7,0

3,4-7,0

WBC

CHEST X-RAY

Cardiomegaly with lung dam and dilatation of aortae,

elevation of diaphragm dextra

WORKING DIAGNOSIS
ST

Elevation Myocardial Infarction (STEMI) Inferior + Right

Ventricle infark onset < 6 Hours

THERAPY
1. O2

2 LPM via nasal canule

2. IVFD

NaCl 0,9% 500 cc/24 hr/IV

3. Lovevox

(Enoxaprin Na) 0,6cc/12 hr/SC

4. Miniaspi

80mg/24 hr/oral

5. Clopidogrel

75 mg/24 hr/oral

6. Atrovastatin
7. Alprazolam
8. Laxative

0,5mg/24 hr/oral

(Laxadine) syr 15ml/24 hr/oral

9. Dobutamin
10.

40 mg/24 hr/oral

7mcg/kgBB/minute/SP (down titrasi)

PPI (Lansoprazole) 30mg/24 hr /oral

Resume

Sinus, HR 83 x/mnt, Normal axis, inferior wall myocardial

infarction and Right Ventricle Infark

Laboratory result SGOT 40, Trop 1,48, HDL 36 mg/dl, LDL 156
mg/dl, CKMB 50,4 , CK 392

Cardiomegaly with lung dam and dilatation of aortae, elevation of

diaphragm dextra

INTRODUCTION
Acute coronary

syndromes (ACS) is a
term for situations where
the blood supplied to the
heart muscle is suddenly
blocked.
described as 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

refers to a spectrum of clinical presentations ranging

from those for ST-segment elevation myocardial
infarction (STEMI) to presentations found in nonSTsegment elevation myocardial infarction (NSTEMI) or
in unstable angina.

It is almost always associated with rupture of an

atherosclerotic plaque and partial or complete
thrombosis of the infarct-related artery.

Myocardial ischemia is caused by imbalance between

myocardial oxygen supply and myocardial oxygen
consumption.

Myocardial infarction (MI) is the rapid development of

myocardial necrosis.

Regions of the Myocardium

Lateral
I, AVL,V5V6

Inferior
II, III, aVF

Anterior /
Septal
V1-V4

Diagnosis

Unstabl
e
Non
Angina
occlusive
thrombus

Non specific
ECG
Normal
cardiac
enzymes

Occluding
NSTEMI
thrombus
sufficient to cause
tissue damage &
mild
myocardial
necrosis
ST depression +/T wave inversion
on
ECG
Elevated cardiac
enzymes

STEMI
Complete thrombus
occlusion
ST elevations on
ECG
Elevated cardiac
enzymes
More severe
symptoms

PATOPHYSIOLOGY
Atherosklerosis, trombosis at coronary
arteries
Decrease the blood flow into the heart
Decrease the supply of oxygen and
nutrition
Ischemia myocard
Necrosis
Imbalance supply and consumption of the
oxygen into the heart
Myocardial infarction

ATHEROSCLEROSIS OF CORONARY ARTERY

RISK FACTORS

Modifiable
Smoking
Hypertension
Diabetes mellitus
Hypercholesterolemia
Obesity
Psychosocial stress
Lack of physical activity

NonModifiable
Gender & Age
Men > 45 years old
Women > 55 years
old
Family history
Heart
Heart disease
disease in
in biological
biological
brother
or
father
brother or father >
> 55
55 years
years
old
old
Heart
Heart disease
disease in
in biological
biological
sister
or
mother
>
sister or mother > 65
65 years
years
old
old

WHO DIAGNOSTIC CRITERIA

Ischemic
symptoms
Diagnostic
ECG changes
Serum cardiac
marker
elevations

Prolonged chest pain

Usually retrosternal location
Dyspnea
Diaphoresis

Changes in serial ECG tracings

Troponin-T
CK-MB
CK
Myoglobin

ISCHEMIC SYMPTOMS

ECG CHANGES

Hyperacute
Phase

Complete
Evolution

Non specific STElevation

T taller and wider

Specific STElevation
T inverted
Q-Pathologic

Old Infarct
Q-Pathologic
ST segment
isoelectric
T normal or inverted

GOAL OF TREATMENT

Relieve pain

Hemodynamic
stabilization

Myocardial
reperfusion

Prevent the
complication

Treatment

Yes

STEMI

Primary PCI

Emergent PCI
available within
90 min ?
No

Fibrinolitic
Theraphy

INITIAL TREATMENT

Bed rest

Oxygen (2-4 lpm)

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.

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%.

INITIAL TREATMENT

Morphine 2-5mg iv (can be administered again in 5-30

minutes later)

Fibrinolytic therapy:
Streptokinase
Tenecteplase

1.5million units iv

0.5mg/kg body weight iv

Anticoagulation therapy:
Low

Molecular Weight Heparins (Fondaparinux)

2.5mg/24hrs/sc for up to 8 days post-MI.

Unfractionated

heparin

Anti Hypertension Drugs

Lipid Lowering Agents

Complication

1. Right Ventricle Infark

in 30-50% cases inferior infark is following by right ventricle

infark

In examination can Find trias: hypotension , clear lung-no ronkhi

and elevation of JVP

Has a different treatment than another ACS, we should avoid to

use drugs such us Nitrates, beta blocker

2. Heart Failure

3. Hipotension (Hemodynamic disturbances)

4. Cardiogenik Syok

5. Arrhythmia

6. AV block/ conduction disturbances

7. Pericarditis

Prognosis
KILLIP CLASSIFICATION
Class
I
II

III
IV

Description
no clinical signs of heart
failure
rales or crackles in the lungs,
an S3, and elevated jugular
venous pressure
acute pulmonary edema
cardiogenic shock or
hypotension (systolic BP < 90
mmHg), and evidence of
peripheral vasoconstriction

http://en.wikipedia.org/wiki/Killip_class

Mortality Rate
(%)
6
17

30 - 40
60 80

THANK YOU