CASE REPORT CARDIOLOGY DEPARTMENT

UNSTABLE ANGINA PECTORIS (UAP)

Presented by: A Mutmainna R C11108324
Supervisor: Dr.dr. Idar Mappangara, SpPD, SpJP.FIHA. FINASIM

CARDIOLOGY DEPARTMENT MEDICAL FACULTY MAKASSAR 2013

UAP - CASE REPORT CARDIOLOGY DEPARTMENT

PATIENTS IDENTITY
Name

: Mr. a Gender : Male Umur : 59 y.o Reg. Number : 640971 Admitted Date : 9th, December 2013

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HISTORY TAKING
Chief

Complaint : Chest pain Structural anamnesis

It was felt since 1 months ago and became worse since 4 hours before admitted to the hospital. The pain was felt in left chest then radiated to the left arm, with the characteristic of pressure sensation. Pain was last more than 20 minutes. Exacerbated with exercises and did not lessen with rest. DOE (+) PND (-)

Nausea (-), epigastric pain (-) Palpitation (-) Cold sweats (+)

UAP - CASE REPORT CARDIOLOGY DEPARTMENT

PAST MEDICAL HISTORY

History

of hypertension (+) since 5 years ago ( uncontrolled ) History of Diabetes (-) History of Dyslipidemia (-) Family History of having CVD (-) History of Smoking (+) since 15 yo, 1 pack/day and stop since 20 years ago

UAP - CASE REPORT CARDIOLOGY DEPARTMENT

PHYSICAL EXAMINATION
General

Appearance : : : 150/90 mmHg : 72 x/minute, regular : 22 x/minute ; : 36,7 C (per axilla)

Moderate-illness /Well nourished/composmentis

Vital Sign BP Pulse RR Temp

Head Examination : Eyes : anemia(-), icterus(-), Neck : JVP R+1 cmH20

cyanosis(-)

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Thoracic Examination : Inspection : Symmetric left and right Palpation : No mass, no tenderness Percussion : Sonor Auscultation : Breath Sound : vesicular, Rh -/-, wh -/Cardiac Examination : Inspection : Ictus Cordis not visible Palpation : Ictus Cordis not palpable Percussion : left border 1 finger from ICS VI midclavicularis line sinistra right border ICS IV parasternalis line dekstra Auscultation : Regular of I/II Heart Sound, murmur (-) gallop (-)

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Abdominal Examination : Inspection : flat, following

movement Palpation : Liver and spleen unpalpable Percussion : Tympani Auscultation: Peristaltic sound (+), normal

breath

Extremities : Oedema (-)

ECG

ECG (25/4/2013)

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ECG INTERPRETATION
Rhythm HR PR interval Axis P Wave QRS complex : Configuration Duration ST segment T wave Conclusion
-

: Sinus Rhyth : 60 bpm : 0.12 sec : -30 LAD : 0,08 sec : Q patologis in lead III, AVF, V1-V2 : 0,08 sec : ST depretion in lead V3-V4 : inverted in lead V3-V4 : Sinus rhythm, HR 60 bpm, LAD, OMI inferoseptal, Anterior iskemik

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LABORATORY FINDINGS
Complete Blood Count WBC : 8,9x103 uL HB: 13,1 g/dl HCT : 40,5% PLT : 362x103 uL

Electrolyte Natrium : 142 Kalium : 4,23 Chloride : 111

Blood chemistry SGOT : 23 SGPT : 22 Ureum : 19 Creatinin : 1,0 Uric acid : 6,2 Glucose : 99 mg/dl

Enzymes CK : 77 u/L CK-MB : 17 u/L Troponin T : <0.02

Lipid Profile Trigliserida : 90 LDL : 102 HDL : 40 Total Cholesterol : 164

ECHOCARDIOGRAM

DESCRIPTION OF WALL MOTION, MASSES, VALVES, PERICARDIUM

Conclusion :
LV sistolic function is good, EF 67% LVH (+) Hypokinetic in mid anterior septal TR Mild Diastolic dysfunction

UAP - CASE REPORT CARDIOLOGY DEPARTMENT

WORKING DIAGNOSIS
UNSTABLE ANGINA PECTORIS

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MANAGEMENT
O2 2-4 LPM via Nasal Canule IVFD NaCl 0,9% 12 dpm Nitrate : ISDN Fasorbid (10mg/cc) 2 mg/hour/SP Anti-platelet aggregation : Aspilet 80 mg 0-1-0 Clopidogrel (Plavix) 75 mg 1-0-0 ACE Inhibitor: captopril 3 x 6.25 mg Anti-coagulant : Arixtra 2,5mg/24/SC Statin : Simvastatin 20mg (0-0-1) Anti-anxiety : Alprazolam 0.5 mg (0-0-1) p.r.n Laxative: Laxadyne syr 0-0-2 C

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PLANNING
ECG

/ day

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DISCUSSION

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CORONARY ARTERY DISEASE

UAP

ACS
CAD Stable Angina Pectoris

NSTEMI

STEMI

DIAGNOSIS

Oxford Handbook of Clinical Medicine 6th

UAP - CASE REPORT CARDIOLOGY DEPARTMENT

CLASSIFICATION

ACS describe a group of conditions resulting from acute myocardial

ischemia (insufficient blood flow to heart muscle) ranging from unstable angina to myocardial infarction.

DIAGNOSIS

ECG
Yes

No

Lab
Yes

No

UAP - CASE REPORT CARDIOLOGY DEPARTMENT

DEFINITION
Angina 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.

PATHOGENESIS
Plaque

UAP - CASE REPORT CARDIOLOGY DEPARTMENT

rupture Thrombus formation Incomplete/ intermittent occlusion of the infactrelated 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

UAP - CASE REPORT CARDIOLOGY DEPARTMENT Figure 1. Pathophysiologic Events Culminating in the Clinical Syndrome of Unstable Angina. Numerous physiologic triggers probably initiate the rupture of a vulnerable plaque. Rupture leads to the activation, adhesion, and aggregation of platelets and the activation of the clotting cascade, resulting in the formation of an occlusive thrombus. If this process leads to complete occlusion of the artery, then acute myocardial infarction with ST-segment elevation occurs. Alternatively, if the process leads to severe stenosis but the artery nonetheless remains patent, then unstable angina occurs.

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CAUSES
Reduction in oxygen supply to myocardium
Coronary artery narrowing from non-occlusive thrombus on a disrupted atherosclerotic plaque Dynamic obstruction by coronary vasospasm or vasoconstriction Severe narrowing without thrombus or spasm progressive atherosclerosis Restenosis after Percutaneous coronary intervention Arterial inflammation and /infection

Increased myocardial oxygen demand in the presence of fixed restricted oxygen supply
Fever, tachycardia, thyrotoxicosis, anemia

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Ischemic symptoms

Prolonged pain (usually >20 mins) constricting,

crushing, squeezing

Usually retrosternal location, radiating to left chest, left arm, can be epigastric

Dyspnea
Diaphoresis Palpitations

Nausea/vomiting
Mild headache

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UAP
If the plaque become unstable caused by bleeding, rupture, or fissure and result in thrombus formation which blocked the vascularisation, angina may occur. Angina become progressive crescendo and have no relation to activity. Moreover, angina can occur anytime, even resting time. This kind of angina called by the Unstable Angina Pectoris

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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

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

UAP - CASE REPORT CARDIOLOGY DEPARTMENT

BRAUNWALD CLASSIFICATION
Characteristic
Severity I II

Class/Category

Details
Symptoms with exertion Subacute symptoms at rest (2-30 d prior)

III

Acute symptoms at rest (within prior 48 h)

Clinical precipitating factor

A B C

Secondary Primary Postinfarction No treatment Usual angina therapy Maximal therapy

Therapy during symptoms

1 2 3

Tan, A Walter. Unsta ble Angina Pectoris Clinical Presentation (updated 7th Dec 2011) http://emedicine.medscape.com/article/159383-overview#showall

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CANADIAN CARDIOVASCULAR SOCIETY FUNCTIONAL CLASSIFICATION

The grading system is as follows: Grade I - Angina with strenuous, rapid, or prolonged exertion (Ordinary physical activity such as climbing stairs does not provoke angina.) Grade II - Slight limitation of ordinary activity (Angina occurs with postprandial, uphill, or rapid walking; when walking more than 2 blocks of level ground or climbing more than 1 flight of stairs; during emotional stress; or in the early hours after awakening.) Grade III - Marked limitation of ordinary activity (Angina occurs with walking 1-2 blocks or climbing a flight of stairs at a normal pace.) Grade IV - Inability to carry on any physical activity without discomfort (Rest pain occurs.)
Tan, A Walter. Unsta ble Angina Pectoris Clinical Presentation (updated 7th Dec 2011) http://emedicine.medscape.com/article/159383-overview#showall

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PROGNOSIS
The presence of any of the following variables constitutes 1 point, with the sum constituting the patient risk score on a scale of 0-7: - Aged 65 years or older - Use of aspirin in the last 7 days - Known coronary stenosis of 50% or greater - Elevated serum cardiac markers - At least 3 risk factors for coronary artery disease (including diabetes mellitus, active smoker, family history of coronary artery disease, hypertension, hypercholesterolemia) - Severe anginal symptoms (2 or more anginal events in the last 24 h) - ST deviation on ECG The inflection point for myocardial infarction or death starts at a TIMI Risk Score of 3. Therefore, patients with a score of 3-7 should be considered for use of intravenous glycoprotein IIb/IIIa agents, heparin (low molecular weight or unfractionated), and early cardiac catheterization

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RISK FACTORS
Modifiable:
Hypertension Diabetes

Non-modifiable:

Mellitus Dyslipidemia Smoking Obesity

Gender: male Age >45 years old Personal history of Coronary Artery Disease Family history of Coronary Artery Disease

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Unstable Angina Therapeutic Goals

Treatment 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).
32

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MANAGEMENT

http://www.cardiosmart.org/HeartDisease

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