CASE REPORT

NON ST-ELEVATED MYOCARDIAL

INFARCTION (NSTEMI)

Chairunissa Isfadina
C014182212

Supervisor: Dr. dr. Abdul Hakim Alkatiri, SpJP, FIHA

NON ST-ELEVATED MYOCARDIAL INFARCTION WITH
ACUTE DECOMPENSATED HEART FAILURE

CASE REPORT
PATIENT’S IDENTITY
 Name: Mrs. DJ
 Age : 61 y.o
 Sex : Female
 Occupation : Housewife
 Religion : Islam
 Address : KP Bakung, Sudiang
 Date of Admission : November 26th, 2019
 MR : 699405
 Work unit : CVCU PJT 3th floor
ANAMNESIS
 Chief Complaint
Chest pain
 History of the disease
Chest pain occurred 7 hours before admission and accompanied by
dyspnea and palpitation. According to the patient, chest pain
sensation was like being stabbed, duration > 20 minutes, with no
diaphoresis. The duration of pain was less than 30 minutes. DOE (+),
PND (-), orthopnea (+).
There was a history of intermittent mild chest pain since 1 week ago.
The patient has a history of heart disease since 2015 and being treated
at RSUD Daya, Makassar.
Diabetes mellitus is denied, hypertension (+) since 4 years ago and
not taking medicine regularly , hypercholesterolemia (+), smoking
habit (-), eating habit: fatty foods.
• Past Medical History
• History of dyspnea (+)
• History of chest pain (+)
• History of hypertension (+)
• History of diabetes mellitus denied
• History of hypercholesterolemia (+)
• FamilIal History
• Heart disease (-)
• Hypertension (-)
• Diabetes melitus (-)
• Habitual History
• History of smoking (-)
• History of alcoholic consumption (-)
• History of eating fatty food (+)
• Lack of physical activity (+)
 Risk Factors
Unmodified
○ Age (61 years old)
○ Menopause
Modified
○ Fatty-rich food consumption
○ Lack of physical activity
○ Hypertension
○ Hyperlipidemia
PHYSICAL EXAMINATION
 General Appearance
Moderately ill/Adequate nutrition/Composmentis
Weight : 45 kg
Height: 147 cm
BMI : 20.83 kg/m2
GCS : E4M6V5
 Vital Signs
BP : 130/70 mmHg
Pulse : 102/minutes
RR: 28/minutes
Temp : 36.5°C
 Head and Neck Examination
Eyes : Anemic conjunctiva (-), icterus (-), isochoric (d
= 2.5/2.5 mm ODS), reflex (+/+), palpebral oedema (-)
Lips : Cyanosis (-)
Neck : JVP R+4 cmH2O, lymph node enlargement (-)
 Thorax
Inspection : Symmetrical
Palpation : No mass, no tenderness
Percussion : Sonor
Auscultation : Vesicular, rhonchi basal bilateral,
wheezing (-)
 Cardiac Examination
Inspection: Invisible ictus cordis
Palpation : Palpable ictus cordis
Percussion
○ Right : 5th ICS right parasternal line
○ Left : 6th ICS anterior axillar line
○ Upper : 2nd ICS.
○ Auscultation : Regular of I/II heart sound, murmur sistolik grade III/VI in apex (+)
 Abdominal Examination
Inspection: Distension (-)
Auscultation : Peristaltic sound (+), normal
Palpation : No mass, no tenderness, liver and spleen are impalpable
Percussion : Tympanic
 Extremities
Warm, oedema (-)
LABORATORY EXAMINATION (06/02/2019)
NO EXAMINATION RESULT REFERENCE VALUE UNIT

HEMATOLOGY

ROUTINE HEMATOLOGY

1 WBC 10.8 4,00-10,0 10^3/ul

2 RBC 4.25 4,00-6,00 10^6/ul

3 HGB 12.8 12,0-16,0 gr/dl

4 HCT 38 37,0-48,0 %

5 MCV 90 80,0-97,0 fL

6 MCH 30 26,5-33,5 Pg

7 MCHC 34 31,5-35,0 gr/dl

8 PLT 180 150-400 10^3/ul

COAGULATION

1 PT 14.9 10-14 Second

2 INR 1.45 --  

3 APTT 29.7 22,0-30,0 Second

BLOOD CHEMISTRY

1 Glucose 217 200 mg/dl

LIPID PROFILE

1 Total Cholesterol 236 200 mg/dl

2 HDL 52 L (> 55), P (> 65) mg/dl

3 LDL 160 < 130 mg/dl

4 Triglyceride 87 200 mg/dl

KIDNEY FUNCTION

1 Ureum 49 10-50 mg/dl

2 Creatinin 1.16 L (<1,3); P( <1,1) mg/dl

LIVER FUNCTION

1 SGOT 110 <38 U/L

2 SGPT 97 <41 U/L

HEART BIOMARERS

1 D- Dimer 3.70 <0,5 ug/L

IMMUNOSEROLOGY

1 Troponin I 1717.8 <0,01 ng/ml

2 HbA1c 6.3 4-6 %

3 Prokalsitonin 17.15 <0.05 ng/ml

ELECTROLYTE

1 Natrium 142 136-145 mmol/l

2 Kalium 4.1 3.5-5.1 mmol/l

3 Chlorida 110 97-111 mmol/l

ELECTROCARDIOGRAPHY
 ECG Interpretation
Rhythm : Sinus rhythm
QRS Rate : 102 bpm
Regularity : Regular
Axis : Normoaxis
P-wave : Normal, duration 0.08 seconds
PR interval : Normal, 0.12 seconds
QRS Complex : Normal
ST Segment : Depression on lead V3 – V6
T-wave : Inverted on III & aVF
Conclusion : Sinus tachycardia, anterolateral & inferior
ischemia, normoaxis
CHEST X-RAY (26/11/2019)
 Interpretation :
 Cardiomegaly with
edema pulmonary sign
 Dilatatio et
atherosclerosis aortae
ECHOCARDIOGRAPHY
1. Severe Mitral Regurgitation with Dilatation of Left Atrial and
Left Ventricle
2. Submitral Inferoposterior Left Ventricular Aneurysm
3. Segmental Hypokinetic
4. Concentric Left Ventricular Hypertrophy
5. Decreased Left Ventricular Systolic Function, EF 47.6%
(TEICH), 46.1% (BIPLANE)
6. Mild Pulmonal Regurgitation
MANAGEMENT
1. IVFD Nacl 0.9%/50 ml/24 hours/intravena
2. Furosemide 5 mg/hours/syringe pump
3. Aspilet 80 mg/24 hours/oral
4. Clopidogrel 70 mg/24 hours/oral
5. Atovastatin 40mg/24 hours/oral
6. Captopril 12,5 mg/8 hoyrs/oral
7. Spironolakton 25mg/24 hours/oral
8. Simarc 2 mg/24 hours/oral
DIAGNOSIS
1. Non- ST Elelevation Myocardial Infraction
Inferiro Very High Risk
2. Post Ventricular Tachycardia unstable
hemodynamic
3. Acute Decompensated Heart Failure
4. Coronary Artery Disease
GRACE SCORE
 Total score: 195 —> di ganti menjadi Killip 3
 Interpretation: High risk mortality
TIMI SCORE
CRUSADE SCORE
NON ST-ELEVATED MYOCARDIAL INFARCTION

DISCUSSION
RISK FACTORS
 Unmodifiable
Age
Sex
Race
Familial history
 Modifiable
Hypertension
Smoking habit
Dyslipidemia
Diabetes mellitus
ETIOLOGY
 Non-occlusive thrombus on existed plaque
 Vasculitic syndromes
 Coronary embolism
 Congenital anomalies of the coronary arteries
 Coronary trauma or aneurysm
 Severe coronary artery spasm (e.g., primary or cocaine-induced)
 Increased blood viscosity (e.g., polycytemia vera, thrombocytosis)
 Spontaneous coronary artery dissection
 Markedly increased myocardial oxygen demand (e.g., severe aortic
stenosis)
PATHOPHYSIOLOGY
CLASSIFICATION

1. STEMI: ST Elevation Myocardial Infarction

2. NSTEMI: Non ST Elevation Myocardial Infarction

3. Unstable angina pectoris

DIAGNOSIS
DIAGNOSIS
 Clinical Manifestations
Chest pain
○ >20 minutes
○ First episode of chest pain with severity of CCS III
○ Cresendo Angina
○ Post-infarct angina
Myocardial infarction chest pain characteristic:
○ Location of pain: most common pain of typical angina are located in
retrosternal/substernal area.
○ Area: pain could radiating to left arm, neck, back, lower jaw, shoulder or
epigastrium.
○ Duration: >20 minutes
○ Quailty: pressure sensation, feeling tight or heavy, like squeezing, or sore.
○ Relieving/aggravating factors: not relieved by sublingual nitrate medicine.
○ Systemic symptoms: dyspnea, cold sweat.
 Physical Examination
Acute mitral valve regurgitation
Third heart sound
Rhonchi
Hypotension
Pulmonary oedema
 Electrocardiography
New horizontal/downsloping ST-segment
depression 0.1 mV on two continuous leads
Inverted T wave ≥ 0.1 mV
 Heart biomarker examination
Increased troponin enzyme 4 hours post-onset
Troponin lasts 2 weeks in circulation
Serial examination should be done in 6-12 hours if the
first examination shows negative result
 CKMB or troponin T
examination is very useful to
diagnose ACS
 CKMB or troponin T
examination is very useful to
diagnose ACS
TREATMENT
 Anti-ischemia
 Beta-blocker  Anti-platelet
 Nitrate  Aspirin
 Calcium channel blocker ○ Loading dose: 150-300
mg
○ Maintenance: 75-100 mg
 Ticagrelor
○ Loading dose:180 mg
○ Maintenance: 2 x 90 mg
 Clopidogrel
○ Loading dose: 300 mg
○ Maintenance: 75 mg/day
TREATMENT
 ACE-inhibitor (to Lisinopril 2.5-20
reduce remodelling mg/day
and post-infarction  Statin (should be given
mortality rate) to all ACS patients
Captopril 2-3 x 6.25-50 (without
mg contraindication) as a
Ramipril 2.5-10 mg/day, anti-inflammatory and
1-2 doses plaque stabilizer drug
 LDL target: <100
mg/dl
TREATMENT
 Anti-coagulant (should be added to anti-platelet
therapy as soon as possible)
Fondaparinux 2.5 mg subcutaneously
Enoksaparin 1 mg/day, twice a day
UFH
○ IV bolus 60 U/g, max 4000 IU
○ IV infuse 12 U/kg, 24-48 hours, max 1000 IU/hour
○ aPTT target 1.5 (2 times of control)
  Reperfusion Therapy

RECOMMENDATIO CLASS LEVEL

N
Urgent PCI < 2 hours Immediate angiography (< 2 hours) to I C
patients with:
- Refractory angina
- Heart failure
- Threatening ventricular arrhytmia
- Unstable hemodynamic
Early invasive PCI To patients with: I A
- GRACE score > 140, or
- 1 high risk criteria
Invasive strategy (72 - 1 high risk criteria I A
hours post-presentation) - Recurrent symptoms
RISK FACTORS MODIFICATION
 Stop smoking
 Weight loss
 Exercise (30-60 minutes, 3-4 times a week)
 Low-fat diet
 Cholesterol primary target < 100 mg/dl
 Reduce blood pressure
 < 130/80 mmHg
 Hyperglicemia control (for DM patients)