NSTEMI

(NON ST ELEVATION
MYOCARDIAL INFARCTION)
By:
Miftahul Jannah (C111 12 172)
Supervisor :
Dr. dr. Khalid Saleh, SpPD-KKV,
FINASIM

PATIENT IDENTITY
O Name

: Mr. N

O Age

: 52 years old

O Address

: Luwu

O MR

: 678790

O Date of Admission

: 17 Juny 2016

History
Taking
Main complain
: Chest pain
O Present history
: Chest pain suffered since one
day before admitted to Wahidin Sudirohusodo hospital.
The pain described like oppressed by a heavy thing and
spread to the jowl and left back and felt more than 20
minutes duration. The pain isnt accompanied with cold
sweating, but while do some activities sometimes the
pain is come also got blown. There's no nausea and
vomiting as well as blown history before. There's no
ortophneu and paroxysmal nocturnal dyspneu (pnd).
Theres disease history with same complain 2 years ago
before use the stant. The patient had been treated in
RSUP Wahidin sudirohusodo more than 2 years with
coronary artery disease diagnose (CAD) and after put the
PERCUTANEUS CORONARY INTERVENTION (PCI). There is
chest pain and hypertension history.There is no DM
history. There is no heart attack history. There is no stroke
history. For behavioral activities: there is smoking history
2 years ago and the patient disclaimed drinking alcohol.

Risk Factors
Non modified risk factors :
age 52 years old
Gender : Male
Modified risk factors :
Hypertension ( on treatment)
Smoking

Physical Examination
O General status:

Moderate Illness / Well nourished/

Composmentis
O Vital sign:
Blood Pressure : 130/80 mmHg
Pulse
: 68 beats/minute
Respiratory Rate : 22 times/minute
Temperature : 36.5 degree celcius

Physical Examination
Head Examination
Eyes

: Anemic -/-,
Icterus -/ Lips
: Cyanosis (-)
Neck :
Lymphadenopathy (-),
JVP R +1 cmH2O

Thorax

Examination

Insp. : Symmetrical
R=L, normochest
Palp. : Respiratory
movement R=L
Perc.: Sonor
Ausc.: Vesicular
Ronchi -/ Wheezing -/-

Physical Examination
Cardiac Examination
Insp. : Ictus cordis wasnt visible
Palp.
: Ictus cordis wasnt palpable
Perc. :
O Upper border 2nd ICS sinistra
O Right border 4th ICS linea parasternalis dextra
O Left border 5th ICS linea axillaris anterior sinistra

Ausc. : I/II heart sound clear and regular.

Murmur (-)

Physical Examination
Abdominal Examination
Insp. : Flat and following breath movement
Ausc.: Peristaltic sound (+), normal
Palp. : Tenderness (-), Liver and spleen was not
palpable
Perc. : Tympany, shifting dullness (-)
Extremities
Edema: Pretibial -/-, Dorsum pedis -/-

Electrocardiography

Rhythm
: Sinus
rhythm
Heart rate : 62 bpm
Axis
: normoaxis
P Wave : Normal
PR interval : 0,16 s
QRS Interval : 0,08 s
ST segment : Norma
T wave : Normal
Conclusion : Sinus
rhythm, HR 62 bpm,
normoaxis,

Pemeriksaan
Hasil
Laboratory
examination
WBC
4.7 [10^3/mm ]

Nilai Normal
4.0 - 10.0

RBC

4.32 [10^6/mm3]

4.50 - 6.50

HGB

12.4 g/dL

14.0 18.0

HCT

36.5 %

40.0 54.0

PLT

137 [10^3/mm3]

150 - 400

PT

10.4 S

10 14

INR

1.00

APTT

23.7 S

22.0 30.0

Ureum

25 mg/dl

10 50

Creatinine

0.88 mg/dl

< 1.3

SGOT

29 U/L

< 38

SGPT

24 U/L

< 41

CK

91 U/L

< 190 U/L

CK-MB

20.3 U/L

< 25

Troponin I

2.70 ng/ml

< 0.01

Natrium

142 mmol/l

136 145

Kalium

3.5 mmol/l

3.5 5.1

Klorida

112 mmol/l

97 111

GDS

149 mg/dl

140

Kolesterol total

101 mg/dl

200

Kolesterol HDL

37 mg/dl

>55

Kolesterol LDL

63 mg/dl

<130

Trigliserida

75 mg/dl

200

Asam Urat

5.5

3.4-7.0

Echocardiography
O Right Ventricular

sistolik normal
O Left ventricular
diastolic dysfunction
grade II

Coronary angiography
O Left main: Normal
O Left anterior descending:

stant patent on proximal

LAD
O Right coronary Artery:
mild total occlusion, distal
filled from LCX
Conclussion:
O Coronary Artery Disease
One vessel

Working Diagnose
O Non ST Elevation Myocardial

Infarction (NSTEMI)
O Coronary Artery Disease post
Percutaneus Coronary
Intervension

THERAPY
O O2 3 lpm via nasal canule
O IVFD NaCl 0.9% 500 ml/24 hours
O Anti Platelet Aggregation:

- Aspirin (loading dose 160 mg) maintenance 1x80 mg

- Clopidogrel (loading 300 mg) maintenance 1x75 mg
O Anti Angina:
ISDN 5 mg/ Sublingual or 1 mg/hours/sp (if chest pain)
O Anti Coagulant :
Fondaparinux: Arixtra 2,5 mg/24 hours/subcutan
O Bisoplorol 2.5 mg/24 hours/ oral
O Simvastatin 40 mg/24 hours/oral
O Alprazolam 0.5 mg 0-0-1
O Lansoprazole 30mg/24 hours/iv
O PLAN: PCI /CABG

DISCUSSION

Definition
O Acute myocardial infarction (AMI) is

an irreversible necrosis of heart

muscle due to prolonged ischemia,
which is suddenly happened.
O Imbalance in oxygen supply and
demand, which is most often caused
by plaque rupture with thrombus
formation in a coronary vessel,
resulting an acute reduction of blood
supply
to
a
portion of
the
myocardium.

Risk Factors
Modifiable
o Smoking
o Hypertension
o Obesity
o Diabetes Mellitus
o Dyslipidemia
o Low HDL < 40
o Elevated LDL / TG

Non Modifiable
o Gender and age:
- male after age 45 y.o
- female after age 55 y.o
o Family History in first
degree
relative > 55 y.o for
male/ 65 y.o for female

VASCULARISATION

PATHOPHYSIOLOGY
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

Biomarkers

MANAGEMENT

Initial diagnosis and early risk stratification

Relief of pain, breathlessness, and anxiety

Restoring coronary flow and myocardial tissue

reperfusion

Management

Oxford Handbook of Clinical Medicine 6th Edition

KILLIP CLASSIFICATION

Complication
O Aritmia
O Heart faillure
O Mechanic complication
O Shock kardiogenik

Thank You