NON ST ELEVATION MYOCARDIAL INFARCTION

St Adinda Srikandi
C014181053
Patient’s Identity
Name : Mrs. LDL
Gender : Female
Age : 63 y.o
Address : Jl. Kelapa Lr.3 No.3
MR : 865648
Occupation : Housewife
Date of Admission : November 11th 2018
 History Taking
Chief complaint : Chest pain
Patients complained of chest pain 48 hours before
she was admitted to the hosital, pain was felt like an
electric shock and spread to the patient’s shoulder.
Duration of attack ± 30 minutes. Nausea and
vomiting exist. The patient feel better when at rest
and the pain become worse when on an activity.

Patient had this chest pain since 3 years

ago and it becomes worse since 2 days
before she was admitted to the hospital
Patient also complain of shortness of
breath whenever she felt the chest pain.
The patient had history of hypertension
since 3 years ago but she is not taking a
regular medications. The patient also had
a diabetes mellitus since 3 months ago
and the patient also not taking a regular
medication.
History Taking

Family History Habit History

There is no history of smoking
Family history of heart disease, There is no history of drinking alcohol
diabetes mellitus and History of eating fatty foods and
hypertension are unknown sweet foods
Physical activity is lacking
 Physical Examination
General Status
Mild illness/ Obese 2/ Compos Mentis
Weight : 71 kg, Height : 150 cm Head and Neck
BMI : 31.5 kg/m2 Eye : Pale Conjunctiva (-),
Icteric sclera (-)
Vital Signs Lip : Cyanosis (-)
Blood Pressure : 130/80mmHg Neck: JVP R + 2 cm H2O
Pulse : 100 bpm, regular Lymphadenopathy (-),
Respiratory : 24x/minutes thyroid enlargement (-)
Temperature : 36.7°C
Physical Examination
Chest Pain
Inspection : Symmetric between left and right hemithorax.
Palpation : No mass, no tenderness.
Percussion : Sonor between left and right chest,
Lung-Liver Junction right ICS 6
Auscultation: Respiratory sound: Vesicular, Ronchi -/-, Wheezing -/-

Heart Examination
Inspection : Heart apex was unvisible
Palpation : Heart apex was unpalpable
Percussion : Upper Heart Border in left ICS II left midclavicular
line, Right heart border in ICS 4 right midclavicular
line, Left heart border in ICS 5 left middle axilla line.
Auscultation : Heart Sounds : S I/II regular, no murmur
Physical Examination

Abdomen Examination
Inspection : Flat
Auscultation: Peristaltic sound (+), normal
Palpation : No mass, no tenderness, liver is unpalpable
Percussion : Tympani

Extremities Examination
Pretibial edema -/-
 Laboratory Examination (10/12/2018)
No Examination Result Reference Value Unit

HAEMATOLOGI (10/12/2018)
Haematolgi Rutin

1 WBC 14,71 4,00-10,0 10^3/ul

2 RBC 5,48 4,00-6,00 10^6/ul

3 HGB 16,4 12,0-16,0 gr/dl

4 HCT 46,3 37,0-48,0 %

5 MCV 84,5 80,0-97,0 fL

6 MCH 29,9 26,5-33,5 Pg

7 MCHC 35,4 31,5-35,0 gr/dl

8 PLT 291 150-400 10^3/ul

Coagulation

1 PT 9,8 10-14 Seconds

2 INR 0,81 --

3 APTT 22,2 22,0-30,0 Seconds

Laboratory Examination (10/12/2018)
No Examination Result Reference Value Unit
1 SGOT 114 <38 U/L
2 SGPT 92 <41 U/L
3 GDS 197 140 Mg/dl
4 Toral cholesterol 216 200 Mg/dl
5 HDL Cholesterol 38 L (> 55), P (> 65) Mg/dl
6 LDL Cholesterol 137 < 130 Mg/dl
7 Triglyceride 157 200 Mg/dl

8 Ureum 38 10-50 Mg/dl

9 Creatinine 0,71 L (<1,3); P( <1,1) Mg/dl

10 CK 1153,58 L(<190);P(<167) U/L

11 CK-MB 61,8 <25 U/L

Laboratory Examination (10/12/2018)

No Examination Result Reference Value Unit

IMMUNOSEROLOGY

1 Troponin I >10.0 <0,01 Ng/ml

Electrolyte

1 Natrium 138 136-145 Mmol/l

2 Kalium 3,1 3,5-5,1 Mmol/l

3 Chlorida 96 97-111 Mmol/l

ELECTROCARDIOGRAPHY (10/12/2018)
 ELECTROCARDIOGRAPHY (10/12/2018)

Rhythm : Sinus Tachycardia

Heart Rate : 107x/menit
Regularity : Regular
Axis : Normoaxis
P wave : 0,08 seconds
PR interval : 0,12 seconds
Complex QRS : normal 0,06 seconds
ST Segment : ST depression in lead II,III,aVF
T wave : normal
Conclusion : Inferior Ischemia
Echocardiography (11/12/2018)

Conclusion:
• Sufficient left ventricular systolic function, 50% ejection f
raction (BIPLANE)
• Concentric LVH
• Segmental hypokinetics
• Moderate diastolic dysfunction
Chest X-Ray (11/12/2018)
Conclusion:
Cardiomegaly + Dilatatio et
atherosclerosis aortae
Left pleural efusion
Working Diagnose

Non ST Elevation Myocardial Infarction

Diabetes Mellitus Type 2

Hypertension

Hypocalemia
Management

Sodium Chloride 0.9% 500 cc / 24 hrs / drips IV

Anti platelet : Aspilet 80mg/24 hours/oral
Anti platelet : Clopidogrel 75mg/24 hours/oral
ACE-inhibitor : Captopril 12,5mg/8 hours/oral
Statin : Atorvastatin 40mg/24 hours/oral
Benzodiazepine : Alprazolam 0,5mg/24 hourss/oral
Nitrat : Nitroglycerin 10mcg/minutes/syringe pump
Beta-blocker : Concor 2,5mg/24 hours/oral
Proton Pump Inhibitor : Lansoprazole 30mg/24 jam/intravena
Insulin : Lantus 0-0-10 IU/Subcutaneous
Insulin : Apidra 6-6-6 IU/Subcutaneous
Calium : KSR 60 mg / 12 hours / oral
DISCUSSION
Definition

NSTEMIs including acute coronary syndromes which are usually (not

always) caused by CHD atherosclerosis, accompanied by the risk of death
and MI (Myocardial Infarction), from angiography and angioscopy
examination show that NSTEMI is often due to tear atherosclerotic
plaques followed by pathological processes with reduced flow coronary
arteries due to the formation of thrombus.
ACS Classification
Etiopathophysiology
Diagnosis

Physical examination
diaphoresis, pale, cold Supported examination
skin, sinus tachycardia, ECG
Anamnesis third or fourth heart
About Symptoms of sounds, basal wet Biomarker
NSTEMI rheumatism, and Imaging
hypotension indicate the
possibility of a large and
high risk ischemic area.

Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
 Therapy
Anti-ischemic And Analgesic Therapy
Oxygen should be given first in patient with NSTEMI.
Oral or intravenous nitrates are useful for pain relief. Intravenous nitroglycerin is
helpful in those with hypertension.
Oral beta-blockers are also useful in pain relief.
Anti-platelet agents
Aspirin should be given to all patients with NSTEMI with initial dose 162-375mg and
the maintenance dose is 75-100mg daily on a long term basis.
Clopidgogrel: immediate dose 300 mg. Maintenance dose: 75mg daily

Anti coagulants
Anti-coagulants recommended in all patients in addition with anti-patelet agents.
Enoxaparin (1mg/kg twice daily)
Fondaparinux 2.5mg daily

Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
 Therapy

Statin and Other Drugs

Statin must be given to each SKA patient (without contraindications) Anti-
inflammatory and stabilizing Plaques
Statin is recommended, irrespective of cholesterol levels, with the aim of achieving
LDL levels <70mg/dl.
Atorvastatin 80mg daily
ACE-inhibitors are indicated in patients with reduced LV systolic function.
Ramipril : 2,5-10 mg/day in 1 or 2 dose
Captopril : 2-3 x 6,25-50 mg
Lisinopril: 2,5-20 mg/day in 1 dose
ARB are indicated in patients who are intolerant with ACE-inhibitors.

Perhimpunan Dokter Spesialis Kardiovaskular Indonesia. Pedoman Tatalaksana Sindrom Koroner Akut.2014
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