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NSTEMI (NON ST ELEVATION MYOCARDIAL INFARCTION)

By: Miftahul Jannah (C111 12 172) Supervisor :
By:
Miftahul Jannah (C111 12 172)
Supervisor :

Dr. dr. Khalid Saleh, SpPD-KKV, FINASIM

PATIENT IDENTITY O Name O Age O Address O MR : Mr. N : 52 years
PATIENT IDENTITY
O Name
O Age
O Address
O MR
: Mr.
N
: 52 years old
: Luwu
: 678790
O Date of Admission
: 17 Juny 2016

History Taking

 Main complain : Chest pain O Present history : Chest pain suffered since one day
 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 isn’t 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).
There’s 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 :
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:
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  Thorax Examination  Eyes : Anemic -/-, Icterus -/- 
Physical Examination
 Head Examination
 Thorax Examination
 Eyes
: Anemic -/-,
Icterus -/-
 Insp. : Symmetrical
R=L, normochest
 Lips
 Neck
: Cyanosis (-)
:
 Palp. : Respiratory
movement R=L
Lymphadenopathy (-),
JVP R +1 cmH2O
 Perc.: Sonor
 Ausc.: Vesicular
 Ronchi -/-
 Wheezing -/-
Physical Examination  Cardiac Examination  Insp. : Ictus cordis wasn’t visible  Palp.  Perc.:
Physical Examination
 Cardiac Examination
 Insp. : Ictus cordis wasn’t visible
 Palp.
 Perc.:
: Ictus cordis wasn’t palpable
O Upper border 2 nd ICS sinistra
O Right border 4 th ICS linea parasternalis dextra
O Left border 5 th 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
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 Rhythm : : Sinus Sinus rhythm rhythm Heart Heart rate rate : : 62 62
Rhythm Rhythm
: : Sinus Sinus
rhythm rhythm
Heart Heart rate rate : : 62 62 bpm bpm
Axis Axis
: : normoaxis normoaxis
P P Wave Wave
: : Normal Normal
PR PR interval interval
: : 0,16 0,16
QRS QRS Interval Interval : : 0,08 0,08 s s
ST ST segment segment : : Norma Norma
T T wave wave
: : Normal Normal
Conclusion Conclusion : : Sinus Sinus
rhythm, rhythm, HR HR 62 62 bpm, bpm,
normoaxis, normoaxis,

Laboratory examination

WBC RBC HGB HCT PLT PT INR APTT Ureum Creatinine SGOT SGPT CK CK-MB Troponin I
WBC
RBC
HGB
HCT
PLT
PT
INR
APTT
Ureum
Creatinine
SGOT
SGPT
CK
CK-MB
Troponin I
Natrium
Kalium
Klorida
GDS
Kolesterol total
Kolesterol HDL
Kolesterol LDL
Trigliserida
4.7 [10^3/mm 3 ]
4.0 - 10.0
4.32 [10^6/mm 3 ]
12.4 g/dL
36.5 %
137 [10^3/mm 3 ]
4.50 - 6.50
14.0 – 18.0
40.0 – 54.0
150 - 400
10.4 S
10 – 14
1.00 -
23.7 S
22.0 – 30.0
25 mg/dl
10 – 50
0.88 mg/dl
29 U/L
24 U/L
< 1.3
< 38
< 41
91 U/L
20.3 U/L
2.70 ng/ml
< 190 U/L
< 25
< 0.01
142 mmol/l
136 – 145
3.5 mmol/l
112 mmol/l
3.5 – 5.1
97 – 111
149 mg/dl
140
101 mg/dl
200
37 mg/dl
>55
63 mg/dl
<130
75 mg/dl
200
Echocardiography O Right Ventricular sistolik normal O Left ventricular diastolic dysfunction grade II
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
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
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
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
DISCUSSION
Definition O Acute myocardial infarction (AMI) is an irreversible necrosis of heart muscle due to prolonged
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 Non Modifiable o Smoking o Hypertension o Obesity o Diabetes Mellitus o Dyslipidemia
Risk Factors
Modifiable
Non Modifiable
o Smoking
o Hypertension
o Obesity
o Diabetes Mellitus
o Dyslipidemia
o Low HDL < 40
o Elevated LDL / TG
o Gender and age:
- male after age 45 y.o
- female after age 55
o Family History in first
degree
relative > 55 y.o for
male/ 65 y.o for female

y.o

VASCULARISATION
VASCULARISATION
PATHOPHYSIOLOGY
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

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
Biomarkers
MANAGEMENT Initial diagnosis and early risk stratification Relief of pain, breathlessness, and anxiety Restoring coronary flow
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 6 Edition

Management

Oxford Handbook of Clinical Medicine 6 th Edition

KILLIP CLASSIFICATION
KILLIP CLASSIFICATION
Complication O Aritmia O Heart faillure O Mechanic complication O Shock kardiogenik
Complication
O Aritmia
O Heart faillure
O Mechanic complication
O Shock kardiogenik
Thank You
Thank You