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NSTEMI

(NON ST ELEVATION MYOCARDIAL
INFARCTION)
BY:
S T. H A R D I YA N T I . S . M A L I K
C111 10 257
SUPERVISOR :
D R . A B D U L H A K I M A L K A T I R I , S P. J P, F I H A

PATIENT IDENTITY

Name
: Mr. M
Age
: 67 years old
MR
: 699300
Day of Admission : Januari 30, 2015

HISTORY TAKING
Chief Complaint : chest pain
Guided Anamnesis :
Chest pain occurred since 6 days before patient is
admitted to the hospital. The pain especially felt
in the left side of the chest and it is radiated to
the back, left arm, and lower jaw. The patient feel
a pressed-like sensation on his chest. Pain
occurred more than 20 minutes, continously. Pain
is not affected by activities or exercise and it is
not relief by resting. There is no dyspneau,
epigastric pain, vomiting, or nausea.

POST MEDICAL HISTORY History of hospitalized in RS Masamba for two days with the same complaint but the patient forget the medication that given to him History of DM (-) History of hypertension (-) History of dyslipidemia is unknown .

PERSONAL HISTORY History of smoking cigarettes (+). since 25 years ago. 1 pack/2 days .

7 kg/m2 (normal) Moderate illness / well nourished / conscious Vital Sign Blood pressure : 130/80 mmHg Pulse rate : 92x/min Respiratory rate : 24x/min Temperature : 36.50 C .GENERAL STATES BW : 62 kg BH : 165 cm BMI : 22.

additional sound : ronchii -/.. icteric (-) Lip : cyanosis (-) Neck : JVP R+2 cmH2O Chest Examination Inspection : symmetric between left and right chest Palpation : no mass. no tenderness Percussion : sonor left = right chest. wheezing -/- .PHYSICAL EXAMINATION Head and Neck Examinations Eye : anemia (-). lung-liver border in right ICS 4 Auscultation : respiratory sound : vesicular.

liver and spleen are not palpable Percussion : tympani (+) Extremities Examination . follows respiratory motion : peristaltic sound (+).Heart Examination Inspection : heart apex is not visible Palpation: heart apex is not palpable Percussion : dull Upper heart border in left ICS II Right heart border in ICS IV right parasternal line Left heart border in ICS V left midclavicular line Auscultation: Heart sounds : S I/II regular. no tenderness. murmur (-) Abdomen Examination Inspection Auscultation : flat. normal Palpation: no mass.

F(<167) U/l CK-MB 27.0 – 47.1) mg/dl Random Blood Glucose 137 mg/dl 140 mg/dl CK 157 U/l M(<190).05 ng/ml .0 gr/dl Hct 39.0 x 103 /mm3 Hb 13.0 – 6.3 U/l < 25 U/l Troponin T 1.0% Plt 156 x 103 /mm3 150 – 400 x 103 /mm3 Ureum 30 mg/dl 10 .6 ng/ml < 0.0 x 103 /mm3 RBC 4.50 mg/dl Creatinin 0.6 x 103 /mm3 4.3).0 – 10.0 – 16.9% 37. F(<1.LABORATORY FINDINGS TEST RESULT NORMAL VALUES WBC 8.9 mg/dl M(<1.8 gr/dl 12.68 x 106 /mm3 4.

SGOT 65 mg/dl < 38 U/l SGPT 66 mg/dl < 41 U/l Uric Acid 4.0).4-7.1 mmol/l Clorida 103 mmol/l 97 – 111 mmol/l .5 – 5.3 mmol/l 3.7) mg/dl Natrium 141 mmol/l 135 – 145 mmol/l Kalium 4.4 mg/dl M(3. F(2.45.

V4. V3. V5. V4. aVL. V6 . aVL.ELECTROCARDIOGRAPHY ST Segment : ST-depressed on lead I. V3. V5 T wave : T inverted on lead I.

V5 : T inverted on lead I. V5. V3. V3.12 s ST Segment T wave : ST-depressed on lead I. HR 70 bpm.INTERPRETATION Rhythm : Sinus rhythm Heart rate : 70 bpm Regularity : reguler Axis : normoaxis P wave : normal PR interval : 0. V4. normoaxis. anterolateral + high lateral wall ischemia . aVL.08 s QRS complex : QS on lead V2 duration 0. aVL. V6 Conclusion : sinus rhythm. V4.

WORKING DIAGNOSIS NON ST ELEVATION MYOCARDIAL INFARCTION (NSTEMI) .

9% 500cc/24 jam Isosorbid dinitrat 5 mg/sublingual Aspilet (anti platelets) loading 160 mg Clopidogrel (anti platelets) loading 300 mg Farsorbid 3 x 10 mg Arixtra (anti koagulan) 2.5mg/24 jam/subkutan Simvastatin (anti cholestrol) 20 mg 0-0-1 Laxadine syrup 0-0-2 cth Alprazolam (anti anxietas) 0.5 mg 0-0-1 .MANAGEMENT AND THERAPY O2 3 lpm via nasal kanul IVFD NaCl 0.

Discussion .

DEFINITION Acute myocardial infarction (AMI) is an irreversible necrosis of heart muscle due to prolonged ischemia. which is most often caused by plaque rupture with thrombus formation in a coronary vessel. which is suddenly happened. Imbalance in oxygen supply and demand. resulting in an acute reduction of blood supply to a portion of the myocardium. .

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DEFINITION Non ST Elevation Myocardial Infarction (NSTEMI) is a syndrome characterized by chest pain resulting from an imbalance between O2 supply & demand. . and is most commonly caused by the inability of atherosclerotic coronary arteries to perfuse the heart under conditions of increased myocardial O2 consumption.

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

heart.org .PATHOPHYSIOLOGY American Heart Association: http://watchlearnlive.

heart.org .American Heart Association: http://watchlearnlive.

American Heart Association: http://watchlearnlive.heart.org .

org .American Heart Association: http://watchlearnlive.heart.

org .heart.American Heart Association: http://watchlearnlive.

American Heart Association: http://watchlearnlive.org .heart.

• Changes in serial ECG tracings.DIAGNOSIS WHO Diagnostic Criteria: • Clinical history of ischemic type chest pain lasting >20 minutes. Oxford Handbook of Clinical Medicine 6th Edition . • Rise and fall of serum cardiac biomarkers such as creatinine kinase-MB fraction and troponin.

more severe. • Feels “squeezing. vomiting. radiated to neck. • Location in substernal. shoulder. or ulnar side of the arm • It is often accompanied by weakness. and lasts longer. ." "pressurelike. jaw. • Not relieved with rest or nitrat. anxiety. similar to discomfort of angina pectoris but commonly occurs at rest. sweating.CLINICAL FEATURES • Deep and visceral chest pain > 20 minutes. nausea. or just "discomfort" but not pain." "griplike." "suffocating" and "heavy”. retrosternal area.

symmetrical.ECG FOR AMI  Hyperacute T wave The earliest signs of AMI are subtle and include increased T wave amplitude over the affected area. Usually evident within hours of the onset of symptoms.  Pathological Q waves Evidence of myocardial necrosis . and pointed (“hyperacute”). T waves become more prominent. It most evident in the anterior chest leads  ST segment Elevation In two or more anatomically contiguous leads.

5 ng/ml Abnormal > 2.BIOMARKERS Biochemical marker for detection of myocardial necrosis Normal value First rise after AMI Peak after AMI Return to normal CK-MB < 5.0 ng/ml Borderline Not detected 3-4 h 24 – 36 h 5 – 14 days .48 h 5 – 21 days Troponin I Detection Limit = 0.0 ng/ml 4h 24 h 72 h Myoglobin < 82 ng/ml 2h 6-8 h 24 h Troponin T Negatif 4h 24 .

MANAGEMENT .

MANAGEMENT Fixing the chest pain and fearness o Bed rest o Diet o O2 2-4 lpm o Nitrat sublingual/oral/IV o Antiplatelet : aspirin and clopidogrel o Morfin/ petidine Stabilizing the hemodynamic (blood pressure and pheripheral pulse control) o β-blocker o Calcium chanel blocker (CCB) o ACE-Inhibitor Reperfusion of the myocard o Thrombolitic .

an S3. and elevated jugular venous pressure III acute pulmonary edema IV cardiogenic shock or hypotension (systolic BP < 90 mmHg).40 60 – 80 . and evidence of peripheral vasoconstriction Mortality Rate (%) 6 17 30 .KILLIP CLASSIFICATION Class Description I no clinical signs of heart failure II rales or crackles in the lungs.

Thank you .