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

THANK YOU