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NON ST ELEVATION

MYOCARDIAL INFARCTION
(NSTEMI)
FELIX HARTANTO
030.10.104

CVD Is a Leading Cause of Death Worldwide


Injuries
Respiratory
Diseases
Diabetes
Other
Chronic
Diseases

9.0%

13.0
%
2.0%

Cancer
13.0
%

Stroke

30.0%

43.0%
CHD

CVD
(16.7 M)

9.0%

33.0%

14.4%

30.0%

Other
CVD

All Other

Rheumatic Heart Disease 2.4%


Inflammatory Heart Disease 2.4%
Hypertensive Heart Disease 5.4%

Adapted from WHO. Preventing Chronic Diseases A Vital Investment 2005.


Adapted from WHO. The Atlas of Heart Disease and Stroke 2004.

ACUTE CORONARY
SYNDROME
Acute Coronary Syndrome (ACS) adalah

istilah yang digunakan untukkumpulan


simptom yang muncul akibat iskemia
miokard akut.
ACS yang terjadi akibat infark otot

jantungdisebut infarkmiokard
Termasuk didalamACS adalah unstable
angina pektoris/infark miokard non
elevasi segmen ST (NonSTEMI), dan
infarkmiokard elevasi segmen

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.

Dari pemeriksaan angiografi dan


angioskopi menunjukkan bahwa
UAP/NSTEMI seringkali diakibatkan oleh
sobeknya plak aterosklerotik yang diikuti
dengan proses patologis dengan akibat
menurunnya atau berkurangnya aliran A.
Coronaria akibat terbentuknya thrombus

Signs of myocardial
ischemia
ECG
ST segment
elevation?
No

Yes
STEMI
(ST-Elevation

Lab

Biochemical
cardiac markers ?

Myocardial Infarction)
Yes

NSTEMI
( Non ST-Elevation
Myocardial Infarction )

No
Unstable Angina

Risk Factors

The spectrum of ACS

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Pathophysiology

Criteria Diagnosis of NSTEMI


1. 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, T-wave
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

Typical vs Atypical Chest Pain


TYPICAL CHEST PAIN

Retrosternal pressure or
heaviness (angina) Radiating
to the left arm, neck, or jaw,
which may be intermittent
(usually lasting for several
minutes) or persistent.
These complaints may be
accompanied by other
symptoms such as diaphoresis,
nausea, abdominal pain,
dyspnoea, and syncope

ATYPICAL CHEST PAIN


Atypical presentations are not

uncommon
These include epigastric pain,

indigestion, stabbing chest pain,


chest pain with some pleuritic
features, or increasing dyspnoea
More often observed in older (.75

years) patients, in women, and in


patients with diabetes, chronic
renal failure, or dementia

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Location of chest pain

Canadian Cardiovascular Society


Grading Scale
Class I : aktivitas fisik biasa/sehari-hari tidak menimbulkan

angina angina timbul pada kegiatan fisik berat


Class II : pembatasan ringan (slight limitation) dari kegiatan

fisik biasa/sehari-hari angina timbul apabila jalan atau


naik tangga dengan cepat
Class III : pembatasan bermakna (marked limitation) dari

aktivitas fisik sehari-hari angina timbul pada jalan


mendatar jarak dekat atau naik tangga pada kondisi normal
Class IV : aktivitas fisik selalu disertai angina dapat timbul

pada keadaan istirahat

Management of
NSTEMI/UAP

Click icon to add classification from


picture folder AZ Graphics

Management strategy
Step 1. initial evaluation

Step 2. Diagnosis validation and risk


assessment
Step 3. invasive strategy

Step 4. revascularization modalities

Step 5. hospital discharge


and post-discharge management
Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Role of
primar
y care
physici
an

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

Initial Treatment

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

GRACE RISK SCORE


Non-ST elevation acute coronary syndrome
Predictor

Score

Age, years

Predictor

Score

Predictor

Score

Killip class

Systolic Blood Pressure (mmHg)

< 40

< 80

63

40 - 49

18

80 89

58

II

21

50 - 59

36

100 - 119

47

III

43

60 - 69

55

120 - 139

37

IV

64

70 - 79

73

140 - 159

26

80

91

160 - 199

11

> 200

Predictor

Score

Predictor

Heart Rate , beats/min

Score

Creatinine (mol/L)

< 70

0 - 34

70-89

35 70

90-109

13

71 105

110 - 149

23

106 140

11

150 - 199

36

141 176

14

> 200

46

177 353

23

354

31

Khalill R et al. Exp Clin Cardiol.2009; 14(2): e25 e30

Predictor

Score

Cardiac
arrest at
admission

43

Elevated
cardiac
markers

15

ST
Segment
deviation

30

Mortality in hospital based on


GRACE RISK SCORE NSTEMI 2011

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Invasive strategy
An invasive strategy (within 72 h after first

presentation) is indicated in patients with:


at least one high-risk criterion (Table 9);
Recurrent symptoms.

Urgent coronary angiography (<2 h) is

recommended in patients at very high ischaemic


risk (refractory angina, with associated heart
failure, life-threatening ventricular arrhythmias, or
haemodynamic instability).
An early invasive strategy (<24 h) is
recommended in Patients with a GRACE score
>140 or with at least one primary high-risk
criterion

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

Conservative strategy (no or


elective angiography)
Patients that fulfil all of the following criteria may be

regarded as low risk and should not routinely be submitted


to early invasive evaluation:
No recurrence of chest pain.

No signs of heart failure.


No abnormalities in the initial ECG or a second

ECG (at 69 h).


No rise in troponin level (at arrival and at 69 h).
No inducible ischaemia.

Hamm CW, et al. European Heart Journal (2011) 32, 29993054

THANK YOU

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