Presented By:Andi Batari Toja MC111 07 181

Supervisor :dr. Pendrik Tandean, SpPDKKV. FINASIM

UNSTABLE ANGINA PECTORISBAGIAN KARDIOLOGI FAKULTAS KEDOKTERANUNIVERSITAS HASANUDDIN

CASE REPORTFEBRUARI 2015

PATIENTS IDENTITYName: Mr. HGender: MaleAge: 44 years oldMR: 694703Date of Admission: January 12th , 2015

History TakingChief complain : Left side chest painPresent history :Chest pain suffered since one day before admitted to Wahidin Sudirohusodo Hospital. The pain is described like through to the back, on the left side of the chest, with cold sweating and radiating to the left arm. The chest pain felt more than 20 minutes duration. The pain felt intermittent. DOE (-), PND (-) Ortopneu (-). Fever (-), Nausea (-), Vomitting (-), Epigastric pain (-). Urination and defecation were normal. History of hypertention (-), Diabetes Mellitus (-), Family history of heart disease does not exist. History of smoking one pack per day.

Risk FactorsNon modified risk factors : Male

Modified risk factors :History of smoking one pack per day

Physical ExaminationGeneral status:Moderatly ill / well nourished / consiousVital sign:Blood Pressure: 110/80 mmHgPulse: 78 beats/minute Respiratory Rate: 24 times/minuteTemperature: 36.7 degree celcius

Physical ExaminationHead ExaminationEyes: Anemic -/-, Icterus -/-Lips: Cyanosis (-)Neck: Lymphadenopathy (-), JVP R +2 cmH2O

Thorax ExaminationInsp. : Symmetrical R=L, normochestPalp. : Respiratory movement R=LPerc.: ResonanceAusc.: VesicularRonchi -/- Wheezing -/-

Physical ExaminationCardiac ExaminationInsp.: Ictus cordis wasnt visiblePalp. : Ictus cordis wasnt palpablePerc.: Dull, normal limitRight Border: Linea parasternalis dextraLeft Border: Linea midclavicularis sinistraAusc. : I/II heart sound clear and regular. Murmur (-)

Physical ExaminationAbdominal Examination Insp.: Flat and following breath movementAusc.: Peristaltic sound (+), normalPalp.: Tenderness (-), Liver and spleen was not palpablePerc.: Tympany, shifting dullness (-)

Extremities Edema: Pretibial -/-, Dorsum pedis -/-

Auxillary ExaminationECG examination (12/01/2015)

ECG InterpretationRhythm: Sinus rhythmP wave: SinusFrequency: 71 beats/minutePR interval: 0.12 secondAxis: NormoaxisQRS complex : QRS duration 0,08 secondST segment: ST depresi on V4-V6T Wave: T inverted V2-V6, I dan avL

Laboratory examination 12/01/2015

DiagnosisUnstable Angina Pectoris

Initial ManagementO22-4 LPM (via nasal kanul)Aspilet 80mg/24jam/oralClopidogrel 75mg/24jam/oralFasorbid 10mg/8jam/oralArixtra 2,5 mg/24jam/subkutanLaxadyne sirup 10cc/24jam/oralSimvastatin 40mg/24jam/oral

Acute Coronary SyndromeUnstable Angina Pectoris

Acute Coronary SyndromeCommon PathologyReflects the development of increasingly sensitive markers of myocardial necrosisDo not differ in therapySpectrum of clinical presentations

DefinitionAngina Pectoris is a syndrome characterized by chest pain resulting from an imbalance between O2 supply & demand, and is most commonly caused by the inability of atherosclerotic coronary arteries to perfuse the heart under conditions of increased myocardial O2 consumption.

Blood supply of hearts Anterior ViewPosterior ViewRight Coronary ArteryLeft Anterior Descending ArteryLeft Circumflex ArteryRight Coronary Artery

Lipid transport disorderInflamation Plaque depositionStable plaquePlaque ruptureErosion Stable angina pectorisThrombosisThrombusAcute coronary syndrome: Unstable angina Myocardial infarction :- Non Q waves- Q wavesPathogenesis

Ischemic SymptomsProlonged pain (usually >20 mins) constricting, crushing, squeezingUsually retrosternal location, radiating to left chest, left arm, can be epigastricDyspneaDiaphoresisPalpitationsNausea/vomiting Mild headache

Non-Modifiable :Family History of CVDAgeGender

Risk FactorsModifiable :SmokingHypertensionDyslipidemiaDiabetes mellitus Obesity

DiagnoseSTEMI

Acute Myocardial Infarction

( Q-wave, non-Q wave )

DiagnosisAt least 2 of the following:

DiagnosisClinical history: Increase frequency and severity of the painPre-existing anginaLast longer than 10 minutes to several hoursNot related to activitiesPain may be intermittenNot relieve by nitrate

ECG Findings

Site of infarctionSign of electrically inert MyocardiumAnteroseptalV1-V3, sometimes V4AnteriorV2-V4. Late R progression in precordial leads.AnterolateralV4-V6LateralV5-V6Extensive AnteriorV1-V6High Lateral I, aVLInferiorII, III, aVFInferolateralII, III, aVF and V5-V6PosteriorInitial R in V1, V2. >0.04s. R>S

Cardiac biomarkers

Cardiac Biomarkers

Cardiac BiomarkersTissueNormal ValueCreatine Kinase (CK)Striated muscle, heart tissue, and brainMale (52-336 U/L)Female (38-176 U/L)Creatine Kinase Myocardiac Band (CK-MB)Heart muscle, few in skeletal muscle

Treatment

TreatmentNitrates:Converted to NO slowing Ca influx and increase Ca uptake by SR dilationVenodilation improve myocardiac perfusionGiven SL for fast and optimal actionTolerance side effect Isosorbide Dinitrate (fasorbid) 5 mg SL tablets every 3-5 minutes up to 3 times; if effect is not sustained, can continue with an IV (Cedocard) 1-5 mg/hour/SPAnti-platelet:Aspirin: Cox-1&2 InhibitorCost effectiveReduce incidence of re-infarction and mortality80-160 mg/d (high dose has bleeding side effect)Clopidogrel: P2Y12 antagonistMore superior to aspirin

Management

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