unstable angina pectoris

UNSTABLE ANGINA PECTORIS

Name: Mahfuzah HazirahSTB: C 111 07 307

Supervisor: dr. Muzakkir Amir, SpJP.FIHA.FICA

PATIENT’S IDENTITY

Name: Ny. Widyaningsih Sex/age: Female/63 yo Ward : CVCU Medical Record: 385330 Date of admission: 07th July 2012 Fee : Askes

HISTORY TAKING

Chief complaint: Chest pain Guided anamnesis:Occurred 3 days prior admission. Getting worse 1 day

ago. The patient complain of pain on the left side of chest. Non-radiated. Dull pain with burning sensation. Duration less then 20 minutes. Frequency of recurrent attack: 6-7 times per day with the increasing intensity. The pain does not triggered by activity. Shortness of breath (+) even at resting state. History of sudden wake at night (-). Patient able to sleep with one pillow. No cough. No nausea and vomit. No epigastric pain.

RISK FACTORS

History of coronary artery disease 3 years ago

History of hypertension 2 years ago History of 1st degree family with

coronary disease and hypertension : mother

History of dyslipidemia

PREVIOUS ILLNESS HISTORY

Diabetes mellitus (-) Gastropathy NSAID Depression (+) Lumbal Spondilosis

PHYSICAL EXAMINATION

GENERAL STATE- Moderate illness/Well nourished/

conscious VITAL SIGN- Blood pressure : 130/90 mmHg- Pulse : 60 bpm- Breathing : 26 x/I- Temperature: 36.5

LOCAL EXAMINATION

EYE: anemic (-) jaundice (-) isochors pupil 2.5mm/2.5mm. Palpebra edema (-/-)

NECK: JVP +2cm H2O. Lymph nodes enlargement (-)

Thorax: Inspection: symmetry both right and left hemithorax, Palpation: vocal fremitus P: symmetry, tumor (-)

tenderness (-)Percussion : sonor for both hemithorax.Auscultation: vesicular breathing, ronchi (-/-)

wheezing (-/-)

Cor: Heart sound S1/S2 reguler Abdomen: peristaltic (+) normal,

hepar-lien are not palpated Extremities : edema (-/-)

ELECTROCARDIOGRAM (09/07/2012)

Interpretation : Rhythm: sinus rhythm QRS rate: HR 65 bpm P wave : 0.04 sec, poor P-wave at aVR PR interval: 0.16 sec QRS complex: 0.04 sec Axis: Left Axis Deviation ST segment: isoelectric T-wave: normal Conclusion: sinus rhythm Hr= 65 bpm

LABORATORIUM FINDING (07/07/2012)

Test Result Test Result

BLOOD TEST CHEMICAL BLOOD TEST

WBC 5.54x10^3/uL Ureum 30 mg/L

RBC 4.79x10^6/uL Creatinine 1.1 mg/L

HGB 14.1 g/dL SGOT 30 U/L

HCT 44.1% SGPT 14 U/L

PLT 244 x 10^3/uL Trigliserida 94

HDL 62

LDL 226

CARDIAC BIOMARKER ELEKTROLIT

CK 415 u/L Natrium 145 mmol

CK-MB 13 u/L Potassium 35 mmol

Troponin-T Negative Cloride 104 mmol

RADIOLOGY FINDINGFOTO THORAX AP (07 JULY 2012) Lung bronchovascular is within normal

limit. No spesific process can be detected at

both side of the lung. Heart enlarged with CTI

13/19.6=0.66, apex embedded. Right sinus , left sinus and both

diaphragma is normal Intact bones Summary: cardiomegaly (HHD)

ANGIOGRAPHY CORONER(11/07/2012)

Conclusion: muscle bridging Advice : conservative

TREATMENT

O2 2-3 lpm k/p IVFD NaCl 0.9% 10 tpm Isosorbid dinitrate 1mg/h/SP Diuretic 40 mg 1-0-0 Amlodipin 5 mg 0-0-1 Clopidogrel 75 mg 0-1-0 Alprazolam 0.5 mg 0-0-1

DISCUSSIONUNSTABLE ANGINA PECTORIS

DEFINITIONAngina pectoris, or angina, is a symptom

of chest pain or pressure that occurs when the heart is not receiving enough blood and oxygen to meet its needs. Unstable angina occurs in unexpected or unpredictable times, such as at rest. Unstable angina symptoms are a medical emergency, and may be a precursor for a heart attack. Thus, medical attention should be sought immediately.

http://www.cardiosmart.org/HeartDisease/

CLINICAL MANIFESTATIONUnstable angina pain can last between 5 and 20 minutes.

Sometimes symptoms can ‘come and go’, Many people describe unstable angina as:

Pain or pressure Tightness A heavy, crushing feeling in the chest, neck, throat, jaw,

shoulder and/or arm Discomfort just below the breastbone Burning similar to heartburn or indigestion Shortness of breath

Because unstable angina occurs without warning and during rest, it can cause severe anxiety. Unstable angina sometimes brings about other symptoms such as nausea, light headedness, or profuse sweating. The pain from

angina may subside if a person takes nitroglycerin.

http://www.cardiosmart.org/HeartDisease

RISK FACTORSUnstable angina results from coronary artery disease

(CAD). Thus, risk factors for the development of CAD are also risk factors for unstable angina:

Smoking Having high

cholesterol levels (hypercholesterolemia) Low HDL cholesterolemia (<40 mg/dl) Hypertrigleseridemia (>200 mg/dl) Hypertension Diabetes mellitus Obesity Having family members (especially parents or

siblings) who have had coronary artery disease (CAD) or a stroke (<65 yo)


ClassificationA classification has been proposed by Braunwald to facilitate the assignation of patients to a particular risk group. This classification takes into account the severity of symptoms, the clinical circumstances surrounding the anginal episode, and the intensity of treatment.

PATHOGENESIS Plaque rupture Thrombus formation Incomplete/

intermittent occlusion of the infact-related vessel to the presence of collateral channels/ to small size of affected vessel.

Cardiology, Desmond G. Julian, J.Campbell Cowan, James M. McLenachan, 8th edition, Elsevier, 2005

DIAGNOSIS

Clinical history

Cardiac enzyme

level

ECG changes


DIAGNOSIS Clinical history: - Increase frequency and severity of the

pain- Pre-existing angina- Last longer than 10 minutes to several

hours- Not related to activities- Pain may be intermitten- Not relieve by nitrate


ECG changes- ST segment depression/ T-wave

inversion- Serial ECG tracing should be recorded

Cardiac enzyme level- CK and CK-MB levels may be mildly

raised - Troponin-T may have a slight increased.


PRINCIPLE MANAGEMENTTreatment for unstable angina focuses

on three goals: stabilizing any plaques that may have

ruptured in order to prevent a heart attack,

relieving symptoms treating the underlying coronary artery

disease (CAD).


MANAGEMENT

Stabilizing the plaque

- Heparin- Clopidogrel - Platelet Glycoprotein (GP) Iib/IIIb

Relieve the sy

mptom

-

Nitrate (nitrogliseride)- Beta-blocker - Calsium channel blocker

Treating underlying

1. Medication- Aspirin - Lipid lowering agent- CAD risk factor treatment2. Lifestyle modification- Healthy diet- Exercise regular- Quitting smoking- Losing weight


CORONARY INTERVENTION PCI Coronary angioplasty (a balloon-tipped

catheter is inserted into a blood vessel in the arm or groin and is advanced through blood vessels and into the heart)

Coronary artery bypass grafting surgery(CABG)
