Cardiology Department Case Report

Medical Faculty January 2016

Hasanuddin University

NSTEMI
(NON ST ELEVATION MYOCARDIAL INFARCTION)
 Patient Identity
• Name : Mrs. H
• Age : 60 years old
• Address : Barru
• Marital Status : Married
• Occupation : Housewife
• Admission on : 06 Januari
2016
• MR : 782213
 History Taking
• Chief complain : Shortness of breath

• Experienced since ± 8 days before admission, and

worsen 2 days ago. Its appear at rest or during lying
down position. Breathing difficulty felt continuously and
worsens during any mild exertion. She frequently woke
up in the midnight for gasping her breath. She always
feeling dizzy and fatigue since 1 year ago when she is
doing any physical activities. No cough. Cold sweat (+)
at palm and soles along with her complain.
• Chest pain (-), but history of chest pain (+) 9 months
ago. Radiated to left arm and relieved at rest.
 History Taking
 Fever (-), history of fever (-), heartburn(+), nausea(-),
vomit(-), Her both legs wasn’t swollen, history of
swollen of her legs (-)
 Micturition and defecation is normal.
 History of rheumatic fever (unknown)
 TB (-), family history with TB (-)
 Asthma (-), family history with asthma (-)
 Family history with CVD (-)
 Cigarette smoking (-)
 Alcoholism (-)
 Previous history
 History of hypertension (+) since ± 10 years ago ;
controlled
 History of DM (+) since ± 10 years ago; controlled.
 History of Cardiovascular disease (+) 9 months ago,
diagnosed as Coronary Artery Disease. She has been
admitted to the hospital with angina pectoris 4 weeks
ago.
 RISK FACTORS
• MODIFIABLE
Hypertension
Diabetes Mellitus
• NON MODIFIABLE
Women
60 years old
History of shortness of breath
History of chest pain
 Physical Examination
 General state:
 Moderate Illness/ Well nourished/Conscious
 Body Weight : 54 kg
 Body Height : 168 cm
 Body Mass Index : 22,2 kg/m2

 Vital state
 Blood Pressure : 130/80 mmHg
 Heart Rate : 88 x/mnt
 Respiratory Rate : 28 x/mnt
 Body Temperature : 36,6 °C
 Physical Examination
Head : Normochepalic
Eye : Anemis (+), Icteric (-)
Pupil : Equal, round, diameter
2,5 mm, reactive to light
Nares : Appearent is normal
Lip : No cyanosis
Neck : JVP +3 CM H2O, no
lymphadenopathy, no thyroid enlargement
 Physical Examination
Chest Examination
 Inspection : Symmetry left=right
 Palpation : Mass (-), tenderness (-)
 Percussion : Sonor left=right; lung-liver
border in ICS VI anterior
 Auscultation: Breath sound;vesicular
Additional sound:
ronchi +/+ (basal) wheezing -
/-
 Physical Examination
Cardiac Examination
 Inspection : Apex was not visible
 Palpation : Apex was not palpable
 Percussion : Right heart border in right
parasternal line, left heart border in left,
midclavicular line ICS V
 Auscultation: Heart sound: SI/II regular,
Additional sound: murmur (-)
 Physical Examination
Abdominal Examination
 Inspection : Convex, following breath
movement
 Auscultation: Peristaltic sound (+), normal
 Palpation : Mass (-), tenderness (-), no
palpable liver and spleen
 Percussion : Timpani (+), Ascites (-)

Extremities examination
 Pretibial edema -/-
 Dorsum pedis edema -/-
ELECTROCARDIOGRAPHY
(ECG)
 ELECTROCARDIOGRAPHY
(ECG)
Result:
• Sinus rythm
• Heart rate 100 beat per minute
• Inferior and lateral wall ischemic
• Left ventricle hypertrophy
• ST elevation at aVR
CHEST X-RAY

Result:
 Pneumonia dextra
 Cardiomegaly with
early sign of lungs
congestion.
 Pleural effusion
sinistra
 LABORATORY
FINDINGS
• Complete Blood Count
Test Result
WBC 9.8 [10^3/mm3]
RBC 3.41 [10^6/mm3]
HGB 10.5 g/dL
HCT 30.7 %
PLT 296 [10^3/mm3]

• Electrolyte
Test Result
Na 144
K 4,8
Cl 110
 LABORATORY
FINDINGS
• Blood Chemistry
Test Result
GDS 152 gr/dl
Ureum 41 mg/dl
Creatinine 1.62 mg/dl
SGOT 29 U/L
SGPT 9 U/L
Total cholesterol 216 mg/dl
LDL 126 mg/dl
HDL 43 mg/dl
Triglyceride 163 mg/dl
 LABORATORY
FINDINGS
• Cardiac Biomarker
Test Result
CK 66.80 U/L
CK-MB 11.3 U/L
Troponin I 0.35 ng/ml
 DIAGNOSIS
NSTEMI
CHF NYHA III
Hypertension grade I
Diabetes mellitus type 2 non obese
Hypercholesterolemia
 THERAPY
O2 4 lpm via nasal canule
Furosemide 40mg/12hours/IV
Captopril 12,5mg/8hours/oral
Isosorbid Dinitrate 10mg/8hours/oral
Simvastatin 20mg/24hours/oral
Clopidogrel 75mg/24hours/oral
Omeprazole 40mg/24hours/IV
Neurodex 1tab/24hours/oral
Urine catheter
DISCUSSION
 AMI Definition
• Acute myocardial infarction (AMI) is an
irreversible necrosis of heart muscle due
to prolonged ischemia, which is suddenly
happened.
• 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 Gender and age:
o Hypertension - male after age 45 y.o
o Obesity - female after age 55 y.o
o Diabetes Mellitus
o Dyslipidemia o Family History in first degree
o Low HDL < 40 relative > 55 y.o for
o Elevated LDL / TG male/ 65 y.o for female
VASCULARISATION
PATHOPHYSIOLOGY
American Heart Association: http://watchlearnlive.heart.org
American Heart Association: http://watchlearnlive.heart.org
1

3
 Biochemical marker for detection of myocardial
necrosis
First rise after Peak after Return to
AMI AMI normal
CK-MB 4h 24 h 72 h
Myoglobin 2h 6-8 h 24 h
Troponin T 4h 24 - 48 h 5 – 21 d
Troponin I 3-4 h 24 – 36 h 5 – 14 d

Biomarkers
MANAGEMENT

Oxford Handbook of Clinical Medicine 6th Edition

 CHF definition
 An imbalance in pump function in which
the heart fails to maintain the circulation
of blood adequately or cardiac output
decreases and is unable to meet the
metabolic demands of the body.
 NYHA
CLASSIFICATION
Class Patient Symptoms

Class I (Mild)
No limitation of physical activity. Ordinary physical activity
does not cause undue fatigue, palpitation, or dyspnea
(shortness of breath).
Class II (Mild) Slight limitation of physical activity. Comfortable at rest, but
ordinary physical activity results in fatigue, palpitation, or
dyspnea.
Class III Marked limitation of physical activity. Comfortable at rest,
(Moderate) but less than ordinary activity causes fatigue, palpitation,
or dyspnea.

Class IV (Severe) Unable to carry out any physical activity without discomfort.
Symptoms of cardiac insufficiency at rest. If any physical
activity is undertaken, discomfort is increased.
 Framingham Criteria
(2 major OR 1 major and 2 minor
criteria)
Major Minor

Paroxysmal Nocturnal Dyspnea  Dyspnea d’effort

Increased of JVP  Cough
Hepatojugular reflux  Extremity edema
Cardiomegaly  Hepatomegaly
Gallop S3  Pleural effusion
Rales or ronchi  Tachycardia  120 bpm
Acute pulmonary edema  Decreased vital pulmonary
Increased venous pressure (>16 mmH2O) capacity (1/3 of maximal)
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