Lateral Non ST-Elevation Myocardial

Infarction with Atrial Fibrilation

Rapid Ventricular Response

CASE REPORT
CARDIOLOGY DEPARTMENT
Faculty of Medicine, Tanjungpura University
Supervisor : Prihati Pujowaskito, dr., Sp.JP(K), MMRS
By : Elok Nur Farida Anggraini, S.Ked

Dustira Hospital, Cimahi

PATIENT IDENTITY
Name : AM
Sex : Male
Age : 73 years old
Address : West Bandung
Occupation : Indonesian Army (Retired)
Admission date : October 2nd, 2017
CHIEF COMPLAINT
Chest pain
HISTORY OF PRESENT ILLNESS
Chest pain that described as a "pressure" and
discomfort in the chest especially on the left side
Since 9 hours before admission to ER
The pain radiates to his left shoulder
The pain duration is about 20 minutes
The complaint is sometimes accompanied by cold
sweating, nausea, and shortness of breath
HISTORY OF PAST ILLNESS
Hypertension (+)
Diabetes Mellitus (+)
Hypercholesterolemia (+)
Tobacco use (+)

Family history of Coronary Artery Disease (-)

PHYSICAL EXAMINATION
Compos Mentis Head : Normocephal
Eye, Ear, Nose, Throat, and Neck
SpO2 : 98%

Eye : Conjunctiva anemic (-), sclera icteric (-)

Vital Sign Ear : Normotia/normotia, secret -/-
BP : 150/100 Nose : Cavum nasi clear/clear, secret -/-
mmHg Throat : Pharynx hyperemic (-)
HR : 110 x/min, Neck : JVP normal, lymph node swelling (-)
iregular, pulsus Pulmo : Vesicular (+/+), wheezing (-/-), rhonki (-/-)
deficits (+) Cor : Regular S1/S2, murmur (-), gallop (-)
RR : 24 x/min Abdomen : Bowel sounds (+), soepel, tenderness (-)
Extermities : edema (-/-), CRT <2s
T : 36,7 C

LABORATORY FINDINGS
HGB : 14,4 g/dL Random glucose level :
RBC : 5,1 x 106 /L 124 mg/dL
WBC : 12.600 /L Creatinine: 1,0 mg/dL
HCT : 41,9 %
PLT : 263.000 /L
MCV : 82,0 fL
CK-MB : 67 U/L
MCH : 28,2 Pq Troponin I : -
MCHC : 34,4 g/dL
RDW : 13,8 % HbsAg : Non reactive
Ba/Eo/Sg/Li/Mo :
0,6/1,1/72,0/19,6/6,7 %
ELECTROCARDIOGRAM

Interpretation
HR : 160 bpm
Rhythm : Atrial Fibrillation
Axis : Left Axis Deviation
QRS complexes : 97 ms
qR complexes : lead I, aVL
rS complexes : lead II, III, aVF
ST segment : ST-depresion
lead I, aVL, V5-6

Conclusion
Lateral NSTEMI
Atrial Fibrillation RVR
Left Anterior Fascicular Block
ANGIOGRAPHY

LM : Stenosis 40% in Distal

LAD : Stenosis 80-90% in
Proximal, stenosis 70-80% in Mid
LCx : CTO (Chronic Total
Occlusion) in Proximal
RCA : Stenosis 70-80% in Mid

Coronary Artery Disease (triple

vessel disease) + CTO
ECHOCARDIOGRAM
Left Ventricular dilatation
Left Ventricular Hypertrophy
Hypokinetic anterolateral
Normo valves
Left Ventricular systolic dysfunction
Left Ventricular normo diastolic function
Right Ventricular systolic function
Thrombus (-)
Ejection Fraction 52%
INITIAL DIAGNOSIS
Clinical diagnosis :
NSTEMI Acute Coronary Syndrome +
Atrial Fibrillation RVR
Anatomical diagnosis :
Lateral Myocardial Infaction with stenosis 40% in distal
LM, stenosis 80-90% in proximal and 70-80% in mid
LAD, stenosis 70-80% in mid RCA, and CTO in proximal
LCx
Etiological diagnosis :
Atherosclerotic disease in LM, LCx, LAD and RCA
MANAGEMENT

Inj. Amiodaron 300 mg diluted in Risk factor control

250 mL 5% dextrose over 30-60 Bleeding evaluation
minutes
Pro CABG
Dabigatran Etexilate 2 x 110 mg
Clopidogrel 1 x 75 mg
Acetylsalicylic acid 1 x 100 mg
Isosorbid dinitrate 3 x 5 mg
Valsartan 1 x 80 mg
Bisoprolol 1 x 5 mg
Rosuvastatin 1 x 20 mg
Metformin 3 x 500 mg
PROGNOSIS
Quo ad vitam : dubia ad malam
Quo ad functionam : dubia ad malam
Quo ad sanactionam : dubia ad malam
THANK YOU