NON ST ELEVATION MYOCARDIAL INFARCT (NSTEMI)
FELIX HARTANTO
030.10.104NON ST ELEVATION MYOCARDIAL INFARCTION(NSTEMI) 1CVD Is
a Leading Cause of Death WorldwideAdapted from WHO. Preventing
Chronic Diseases A Vital Investment 2005.Adapted from WHO. The
Atlas of Heart Disease and Stroke 2004.
30.0%30.0%9.0%2.0%13.0%9.0%13.0%All OtherCVD(16.7
M)CancerInjuriesRespiratoryDiseasesDiabetesOther Chronic
Diseases
33.0%43.0%14.4%StrokeOtherCVDCHDRheumatic Heart Disease
2.4%Inflammatory Heart Disease 2.4%Hypertensive Heart Disease
5.4%2ACUTE CORONARY SYNDROMEAcute 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
ST(STEMI)
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.
4 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
thrombusSTEMI
(ST-Elevation
Myocardial Infarction)NoYesYesNoNSTEMI
( Non ST-Elevation
Myocardial Infarction )Unstable AnginaSigns of myocardial
ischemia Biochemical cardiac markers ?ECGLabST segment
elevation?Risk FactorsThe spectrum of ACS
Hamm CW, et al. European Heart Journal (2011) 32,
29993054Pathophysiology
Criteria Diagnosis of NSTEMITypical 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 sweatECG : ST segment depression
0.05 mV, T-wave inversion (> 0.1 mV) : at least 2 pairs of leads
The increase in cardiac enzymes : CK, CK-MB, troponin T Picture
hypokinetic/akinetic myocardial segments by echocardiography
examinationTypical vs Atypical Chest PainATYPICAL 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
dementiaTYPICAL 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 syncopeHamm CW,
et al. European Heart Journal (2011) 32, 29993054Location of chest
pain
Canadian Cardiovascular Society Grading ScaleClass 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 istirahatManagement of NSTEMI/UAP
Management strategyStep 1. initial evaluationStep 2. Diagnosis
validation and riskassessmentStep 3. invasive strategyStep 5.
hospital dischargeand post-discharge managementStep 4.
revascularization modalitiesHamm CW, et al. European Heart Journal
(2011) 32, 29993054Role of primary care physicianManagement Oxygen
Anti-ischemia drugsnitratesmorphin / pethidinbeta blockerACE
inhibitor Antiplatelet drugsaspirinclopidogrelGP IIb/IIIa inhibitor
Anticoagulation drugsunfractionated heparinlow molecular weight
heparin (LMWH) Adjuvant therapyInitial Treatment
Hamm CW, et al. European Heart Journal (2011) 32, 29993054GRACE
RISK SCORENon-ST elevation acute coronary syndrome
PredictorScoreAge, years< 40040 - 491850 - 593660 - 695570 -
79738091PredictorScoreHeart Rate , beats/min<
70070-89790-10913110 - 14923150 - 19936>
20046PredictorScoreSystolic Blood Pressure (mmHg)< 806380
8958100 - 11947120 - 13937140 - 15926160 - 19911>
2000PredictorScoreCreatinine (mol/L)0 - 34235 70571 1058106
14011141 17614177 35323 35431PredictorScoreKillip
classI0II21III43IV64PredictorScoreCardiac arrest at admission
43Elevated cardiac markers15ST Segment deviation30Khalill R et al.
Exp Clin Cardiol.2009; 14(2): e25 e30Mortality in hospital based on
GRACE RISK SCORE NSTEMI 2011
Hamm CW, et al. European Heart Journal (2011) 32,
29993054Invasive strategyAn 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 (
