NSTEMI

(NON ST ELEVATION MYOCARDIAL

INFARCTION)

BY:
ANDI QAUTSAR SYAHREZO
C111 11 003

SUPERVISOR :
DR. ABDUL HAKIM ALKATIRI, SPJP-FIHA
PATIENT IDENTITY
Name : Mrs. H.A
Age : 67 years old
MR : 480840
Day of Admission : October 22nd, 2015
 HISTORY TAKING
Main complain : Chest pain

Present history :

Chest pain suffered since one day before admitted to Wahidin

Sudirohusodo Hospital. The pain is described like through to the back,

on the left side of the chest, with cold sweating and radiating to the

left arm. The chest pain felt more than 20 minutes duration. The pain

felt intermittent. There is no Dispnea On Effort (DOE), There is no

Paroxysmal Nocturnal Dispnea (PND), There is no Ortopneu. There is no

Fever, Nausea and Vomitting. There is history of Epigastric pain since 5

years ago. There is History of hypertension since 3 years ago, there is

no history of Diabetes Mellitus, Family history of heart disease did exist

(little sister 55yo and older brother 68yo) . There is no history of

smoking.
RISK FACTORS
Nonmodified risk factors :
age 66 years old
Family History of heart disease

Modified risk factors :

Hypertension
Obesity
Dislipidemia
PHYSICAL EXAMINATION
General status:
Moderatly ill / Obesity/ Composmentis
Vital sign:
Blood Pressure : 170/90 mmHg
Pulse : 66 beats/minute
Respiratory Rate : 20 times/minute
Temperature : 36.5 degree celcius
 PHYSICAL EXAMINATION
Head Examination Thorax Examination
Eyes : Anemic -/-, Insp. : Symmetrical R=L,
Icterus -/- normochest
Lips : Cyanosis (-) Palp. : Respiratory
Neck : movement R=L
Lymphadenopathy (-), Perc.: Sonor
JVP R +2 cmH2O Ausc.: Vesicular
Ronchi -/-
Wheezing -/-
 PHYSICAL EXAMINATION
Cardiac Examination
Insp. : Ictus cordis wasnt visible
Palp. : Ictus cordis wasnt palpable

Perc. :

Upper border 2nd ICS sinistra

Right border 4th ICS linea parasternalis dextra
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 : 66 bpm
Axis : normoaxis
P Wave : Normal
PR interval : 0,08 s
Duration QRS: 0,12 s
in lead V2
ST segment : ST
depresion at
V3,V4,V5,V6
T wave : T inverted
on V1-V6, I, AVL

Conclusion : Sinus
rhythm, HR 66 bpm,
normoaxis,
Anterolateral wall
ischemia
 HEMATOLOGY RESULT NORMAL VALUE
WBC 5,8x 103/mm3 4.0-10.0 x 103
RBC 4,07 x 106/mm3 4.0-6.0 x 106
HGB 12,7 gr/dL 12-16
HCT 38,3% 37-48
PLT 152x 103/mm3 150-400 x 103

LABORATOR Ureum 27 10-50 mg/dl

Creatinin 0,8 0.5-1.2 mg/dl

Y SGOT 32 <35 U/L

SGPT 25 <45 U/L

EXAMINATIO Na 142 136-145 mmol/l

K 4,2 3.5-5.1 mmol/l

N Cl 115
99
97-111 mmol/l
CK L(<190U/L) P(<167U/L)

22/10/2015 CK-MB 12 <25U/L

Troponin I 0,04 <0,01
Kolesterol total 229 200 mg/dl
Asam urat 5,5 L 3,4-7,0 ; P 2,4-5,7
HDL 44 L>55; P>65
LDL 171 <130 mg/dl
Trigliserida 215 200 mg/dl
RADIOLOGY FINDINGS
Chest X-Ray
Cardiomegaly and
Dilatatio et Elongatio Aortae
ECHOCARDIOGRAPHY
Left ventricular diastolic dysfunction grade I
Concentric hypertrophy left ventricular
Mild MR
CORONARY ANGIOGRAPHY
Left main: osteal stenosis 50%, distal stenosis 60%
Left anterior descending: osteal total occlusion, distal
filled from RCA
Left circumflex: proximal total occlusion, distal filled from
RCA
Right coronary Artery: mild stenosis 40%
Conclussion:
Coronary Artery Two Vessel Disease+ left main disease
WORKING DIAGNOSE
Non ST Elevation Myocardial Infarction
(NSTEMI)
Coronary Artery Disease 2 Vessels Disease
Hypertensive Heart Disease
Dyspepsia
Dyslipidemia
THERAPY
O2 2-4 lpm via nasal canule
IVFD NaCl 0.9% 500 ml/24 hours
Anti Platelet Aggregation:
- Aspirin (loading dose 160 mg) maintenance 1x80 mg
- Clopidogrel (loading 300 mg) maintenance 1x75 mg
Anti Angina:
- ISDN 1mg/hr/sp
Anti Coagulant:
- Fondaparinux 2.5 mg/24 hours/SC
Simvastatin 40 mg/24 hours/oral
Bisoprolol 2,5 mg -0-0
Alprazolam 0.5 mg 0-0-1
Lansoprazole 30mg/24j/iv
PLAN: CABG
DISCUSSION
 DEFINITION
Acute myocardial infarction (AMI) is an
irreversible necrosis of heart muscle due to
prolonged ischemia, which is suddenly
happened.
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 Non Modifiable
o Smoking o Gender and age:
o Hypertension - male after age 45 y.o
o Obesity - female after age 55 y.o
o Diabetes Mellitus
o Dyslipidemia o Family History in first
o Low HDL < 40 degree
o Elevated LDL / TG 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
 Biochemical marker for detection of myocardial
necrosis
First rise Peak after Return to
after AMI AMI normal
CK-MB 4h 24 h 72 h
Myoglobin 2h 6-8 h 24 h
Troponin T 4h 24 - 48 h 5 21 d
Troponin I 3-4 h 24 36 h 5 14 d

BIOMARKERS
MANAGEMENT

Oxford Handbook of Clinical Medicine 6th Edition

Thank You