NSTEMI

(NON ST ELEVATION MYOCARDIAL INFARCTION)

By:
FAUZIAH
Supervisor :
DR. ABDUL HAKIM ALKATIRI, SPJP-FIHA

DEPARTMENT OF CARDIOLOGY AND VASCULAR MEDICINE

MEDICAL FACULTY OF HASANUDDIN UNIVERSITY
MAKASSAR
2016
 PATIENT IDENTITY

Name : Ms. S
Age : 75 years old
Occupation : Farmer
Address : Moncongloe lappara, Maros
MR : 727033
Date of Admission : January 13th 2016
 HISTORY TAKING

Chief complaint : Chest pain

Present Illness History :
Left chest pain felt since 18 hours ago before admission
Occurs suddenly when the patient was in washroom
Described as oppressed pain and felt through the left arm,
intermittently, duration of pain more than 20 minutes. With cold
sweating.
There is orthopneu, and DOE.
Cough, no fever, no nausea and and no vomiting
 HISTORY TAKING

Past history:
history of chest pain on and off
History of hypertention since 1 year ago
History of heart disease is none
History of Diabetes Mellitus is none
HISTORY TAKING

Personal Life History :

No history of alcohol consumption
No history of smoking
No history of heart disease in the family
No history of diabetes in the family
Past Treatment History :
No history of hospital admission
PHYSICAL EXAMINATION
General Status
Moderate illness / well nourished/ Composmentis
Weight : 45 kg
Height: 155 cm
BMI : 18.7 kg/m2
Vital Status
Blood pressure : 180/100 mmHg
Heart rate : 92 bpm
Respiratory rate : 26 rpm
Temperature : 36,5 oC
PHYSICAL EXAMINATION
Head : anemic (-) icteric (-)
Neck : JVP R+2 cmH2O
Lung :
Inspection : symmetry left=right
Palpation : no tenderness, normal vocal fremity
Percussion : sonor
Auscultation : vesicular, ronchi +/+ at basal lung,
wheezing -/-
PHYSICAL EXAMINATION
Cor :
Inspection : ictus cordis not visible
Palpation : ictus cordis not palpable, thrill (-)
Percussion :
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea axillaris anterior sinistra
Auscultation : heart sound I/II pure, regular, murmur (-)
PHYSICAL EXAMINATION

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

Extremities :
Edema (-)
 ELECTROCARDIOGRAPHY
Sinus tachycardia
HR : 107bpm
Regularity: regular
Axis : normoaxis
PR interval : 0.20 s
QRS rate : 0.08 s
QRS complex : S V1+ R
V5/V6> 35mm
ST segmen :
ST segmen elevation on
lead V1-V3
ST depresion on Lead I,
aVL, V5, V6

Conclusion :
Sinus tachycardia, HR :
107bpm, anteroseptal
walls myocardial
infarction,
lateral wall ischemic.
LABORATORY RESULTS
TEST RESULT NORMAL TEST RESULT NORMAL
VALUE VALUE
WBC 17.700 x 103/uL 4.0 10.0 x 103 Tot.Choles 238mg/dl 200
HDL 51 mg/dl >59
RBC 4.6 4.0 6.0 x 106 LDL 171 mg/dl 130
HGB 12.1 12 16 Trigliserida 134 mg/dl 200
HCT 39 37 48 Ureum 40 10-50
PLT 279x 103/uL 150 400 x 103 Kreatinin 0.96 0,5-1,2
Troponin I 1.61 <0,01
PT 12.3 10 - 14
CK 154,00 <190
APTT 22.7 22,0 - 30,0
CKMB 19.5 <25
INR 1.18
Natrium 148 136 - 145
GDS 363mg/dl 140
Kalium 3,1 3,5 - 5,1
GD2PP - <200
Klorida 113 97 - 111
SGOT 28 u/L <38
Asam Urat - 3,4-7,0
SGPT 26 u/L <41
CHEST X-RAY

Result :
Cardiomegaly with
signs of pulmonary
edema
Dilatatatio elongation
et atherosclerosis
aortae
DIAGNOSIS

STEMI onset >12 hours, KILLIP II

Hipertension gr.I
Stress hyperglycemia dd DM type II non
obese
hypokalemia
TREATMENT
Oksigen 2-4 liter per menit via nasal kanul
IVFD NaCl 0,9% 500 cc/24 jam/IV
Aspirin 160mg (loading dose) 80mg/24j/oral
Clopidogrel 300mg (loading dose) 75 mg/24 jam/oral
Isosorbid Dinitrat 10mg/jam/oral
Arixtra 2,5mg/24j/SC
furosemide 40mg/12jam/IV
Captopril 12.5mg/8jam/oral
Simvastatin 20 mg/24 jam/oral
Alprazolam 0,5mg/24jam/oral
Laxadyne syr 10ml/24jam/oral
KSR 600mg/12jam/oral
DISCUSSION
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 infarction
(heart attack).
PATOPHYSIOLOGY
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
 Normal myocardium metabolizes fatty acid and glucose to CO2
and H2O
Severe O2 depriviation, fatty acid cannot be oxidized and
glucoseis degraded into lactate, intracellular pH is reduced,
intramyocardial stores of high energy phosphates is reduced.
Impaired cell membrane function leads to leakage of K and
uptake of Na by myocytes, as well as increase in cytosolic Ca.
As the results:
if total occlusion in the absence of collaterals is more than 20
mins, it can causes permanent myocardial necrosis
Electrical instability,which can lead to ventricular premature
beats, ventricular tachycardia or ventricular fibrillation
Patophysiology
WHO DIAGNOSTIC CRITERIA
Prolonged chest pain
Ischemic Usually retrosternal location
symptoms

Dyspnea
Diaphoresis

Diagnostic
ECG changes

Serum cardiac Troponin-T

CK-MB
marker CK
elevations Myoglobin
RISK FACTORS

Non-
Modifiable
Modifiable
Smoking
Gender & Age
Hypertension Men > 45 years old
Diabetes mellitus Women > 55 years old

Hypercholesterolemia
Family history
Obesity Heart disease in biological
brother or father > 55 years
Psychosocial stress old
Heart disease in biological
Lack of physical activity sister or mother > 65 years old
CARDIAC BIOMARKERS
GOAL OF TREATMENT

Hemodynamic
Relieve pain
stabilization

Myocardial Prevent the

reperfusionn complication
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%.
Morphine 2-5mg iv (can be administered again in 5-30 minutes later)
Fibrinolytic therapy:
Streptokinase 1.5million units iv
Actilyse 0.75mg/kg weight body
Anticoagulation therapy:
Low Molecular Weight Heparins (Fluxum) 0.4cc/sc for up to 8 days post-MI.
Unfractionated heparin
Anti Hypertension Drugs
Lipid Lowering Agents
Complication
THANK YOU