Nstemi

NON ST ELEVATION MYOCARDIAL INFARCTION (NSTEMI) Present by Fadlia. N (C 111 09 406) Supervisor : Prof.Dr. dr. Ali Aspar M, Sp.PD, Sp.JP(K), FIHA, FAsCC, FINASIM, FICA Department of Cardiology and Vascular Medicine Medical Faculty of Hasanuddin University Makassar 2014

Patient Identity  Name

: Mr. N  Age : 51 years old  MR : 678790  Day of Admission : September 4, 2014

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 Mangkutana 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

General States BW : 62 kg BH : 165 cm BMI : 22,7 kg/m2 (normal) Moderate illness / well nourished / conscious

Vital Sign  Blood pressure : 110/80 mmHg  Pulse rate : 92x/min  Respiratory rate : 24x/min  Temperature : 36,50 C

Physical Examination Head and Neck Examinations Eye : anemia (-), 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, lung-liver border in right ICS 4 Auscultation : respiratory sound : vesicular; additional sound : ronchii -/- , wheezing -/-

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, murmur (-) Abdomen Examination Inspection : flat, follows respiratory motion Auscultation : peristaltic sound (+), normal Palpation : no mass, no tenderness, liver and spleen are not palpable Percussion : tympani (+) Extremities Examination Warm akral Edema -/-

Laboratory Findings TEST

RESULT

NORMAL VALUES

WBC

8,6 x 103 /mm3

4,0 – 10,0 x 103 /mm3

RBC

4,68 x 106 /mm3

4,0 – 6,0 x 103 /mm3

Hb

13,8 gr/dl

12,0 – 16,0 gr/dl

Hct

39,9%

37,0 – 47,0%

Plt

156 x 103 /mm3

150 – 400 x 103 /mm3

Ureum

30 mg/dl

10 - 50 mg/dl

Creatinin

0,9 mg/dl

M(<1,3); F(<1,1) mg/dl

Random Blood Glucose

137 mg/dl

140 mg/dl

CK

157 U/l

M(<190); F(<167) U/l

CK-MB

27,3 U/l

< 25 U/l

Troponin T

1,6 ng/ml

< 0,05 ng/ml

SGOT

65 mg/dl

< 38 U/l

SGPT

66 mg/dl

< 41 U/l

Uric Acid

4,4 mg/dl

M(3,4-7,0); F(2,4-5,7) mg/dl

Natrium

141 mmol/l

135 – 145 mmol/l

Kalium

4,3 mmol/l

3,5 – 5,1 mmol/l

Clorida

103 mmol/l

97 – 111 mmol/l

Radiology Examination

Cardiomegaly (CTI 0,54) with dilatatio aortae

Electrocardiography

ST Segment : ST-depressed on lead I, aVL, V3, V4, V5 T wave : T inverted on lead I, aVL, V , V , V ,

Interpretation Rhythm Heart rate Regularity Axis P wave PR interval

QRS complex

: Sinus rhythm : 70 bpm : reguler : normoaxis : normal : 0,08 s

: QS on lead V2 duration 0,12 s

ST Segment : ST-depressed on lead I, aVL, V3, V4, V5 T wave : T inverted on lead I, aVL, V3, V4, V5, V6 Conclusion : sinus rhythm, HR 70 bpm, normoaxis, anterolateral + high lateral wall ischemia

Working Diagnosis

NON ST ELEVATION MYOCARDIAL INFARCTION (NSTEMI)

Management and Therapy O2 3 lpm via nasal kanul IVFD NaCl 0,9% 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

DISCUSSION

NSTEMI The death of the heart muscle that is characterized by acute symptoms of typical angina with ECG abnormalities (without ST segment elevation) and an increase in cardiac enzymes.

Risk Factors Modifiable Smoking Hypertension Obesity

Nonmodifiable Gender and Age male > 45 y.o female > 55 y.o

Diabetes Mellitus Dyslipidemia Low HDL < 40 Elevated LDL / TG

Family History male < 55 y.o female < 65 y.o

Signs of myocardial ischemia ECG Yes

ST segment elevation?

STEMI (ST-Elevation

No

Lab

↑ Biochemical cardiac markers ?

Myocardial Infarction) Yes

NSTEMI ( Non ST-Elevation Myocardial Infarction )

No

Unstable Angina

Pathophysiology

Criteria Diagnosis of NSTEMI Typical infarction angina symptoms : chest pain substernal or retrosternal are like pressure, sharp, stabbing, heaviness radiating to the left arm, neck, lower jaw, and back, duration > 20 minutes, accompanied by systemic symptoms such as nausea, vomiting, cold sweat 2. ECG : ST segment depression ≥ 0.05 mV, Twave inversion (> 0.1 mV) : at least 2 pairs of leads 3. The increase in cardiac enzymes : CK, CK-MB, troponin T 4. Picture hypokinetic/akinetic myocardial segments by echocardiography examination 1.

Management  Oxygen  Anti-ischemia drugs  nitrates  morphin / pethidin  beta blocker  ACE inhibitor  Antiplatelet drugs  aspirin  clopidogrel  GP IIb/IIIa inhibitor  Anticoagulation drugs  unfractionated heparin  low molecular weight heparin (LMWH)  Adjuvant therapy

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