CASE REPORT

U N S TA B L E A N G I N A P E C T O R I S
M U YA B A R AT I R I L I N D A
PA H I S TA PA M B E R I A S K I

S U P E RV I S O R :
D R . Z A E N A B D J A F A R , S P. P D , F I N A S I M , M K E S , S P. J P ( K ) , F I H A
PATIENT'S IDENTITY
■ Name : Mr. US

■ Age : 51 years old

■ Address : DSN Poreang

■ Admitted on : 25 Okt 2019

■ MR : 899570
ANAMNESIS
❑ Chief Complain : Chestpain
❑ Recent Disease History
▪ Chest pain was felt since 2 days ago before admitted to the
hospital
▪ Depressed chest pain but didn't radiated
▪ Chest pain lasts for >20 minutes with cold sweat
▪ There were no dispneu
▪ There were no history of nausea and vomitting
ANEMNESIS
❑ Past Disease History
▪ History of appendectomy 1 week ago
▪ There was history of chest pain
▪ There was a history of hypertension and take the
medicine (amlodipine 5 mg) but not regularly
▪ There was no history of diabetes mellitus
ANEMNESIS
❑ Familial History
▪ There was no familial history of CAD
▪ There was familial history of hypertension
▪ There was no familial history of diabetes mellitus
❑ Habitual History
▪ 10 years of smoking
▪ Not drinking alcohol
RISK FACTORS
❑ Modifiable Risk Factors
▪ Hypertension
▪ Smoking
▪ Obesitas
❑ Unmodifiable Risk Factors
▪ Gender (Male)
PHYSICAL EXAMINATION
 General Status
▪ Moderately ill/Obesitas/Composmentis (E4M6V5)
▪ Weight : 70 kg
▪ Height : 161 cm
▪ Body Mass Index : 27 kg/m2
 Vital Signs
▪ Blood Pressure : 170/90 mmHg
▪ Heart Rate : 83x/minute
▪ Respiratory Rate : 20x/minute
▪ Temperature : 36,5 0C
▪ VAS : 5-6
 PHYSICAL EXAMINATION
❑ Head and Neck Examination
▪ Hair : There was no alopecia
▪ Eyes : Anemic (-), Icteric (-), isochore pupil (d=2 mm ODS)
▪ Face : There were no tenderness on frontal and maxillary sinus
▪ Lips : Cyanosis (-)
▪ Mouth : Coated tongue (-), Tonsil T1-T1
▪ Neck : JVP R+2cm H2O, there were no lymphadenopathy and thyroid gland enlargement,
neck stiffness (-)

❑ Thorax Examination
 Inspection : symmetric, there were no abnormality of shape and chest wall
 Palpation : there was no tumor mass, tenderness and vocal fremitus was not increased
 Percussion : sonor on left and right, lung hepar border as high as right ICS 5
 Auscultation : vesicular breath sound, additional sound rhonchi (-) wheezing (-)
PHYSICAL EXAMINATION
 Heart Examination
• Inspection : Ictus cordis not visible
▪ Palpation : Ictus cordis not palpable
▪ Percussion : Right border in right parasternal ICS 5, left border in anterior linea
axillary ICS 6, and upper border in ICS 2
▪ Auscultation : SI/SII pure regular, there was no murmur
❑ Abdomen Examination
• Inspection : Flat, follow breathing movement, ascites (-), post op wound, active
bleeding (-), pus (-)
▪ Auscultation : Peristaltic (+)
▪ Palpation : There were no tumor mass, tenderness, and hepar-lien enlargement
▪ Percussion : Tympani (+)
 Extremity Examination
warm acral, oedema (-), CRT <2 seconds, ulcus (-)
 No Examination Result Reference Unit
LABORATORY HEMATOLOGY

RESULT 1 WBC
Routine Hematology
6,67 4,00-10,0 10^3/ul

25/10/2019 2 RBC 4,43 4,00-6,00 10^6/ul

3 HGB 12,3 12,0-16,0 gr/dl
4 HCT 34,9 37,0-48,0 %
5 MCV 78,8 80,0-97,0 fL
6 MCH 27,8 26,5-33,5 pg
7 MCHC 35,2 31,5-35,0 gr/dl
8 PLT 278 150-400 10^3/ul
Coagulation
1 PT 11,7 10-14 seconds
2 INR 1,14 --
3 APTT 33,8 22,0-30,0 seconds
 No Examination Result Reference Unit

LABORATORY Glucose

RESULT
1 GDS 81 140 Mg/dl
KIDNEY FUNCTION

25/10/2019 1 Ureum 28 10-50 Mg/dl

2 Creatinine 0,80 L (<1,3); P( <1,1) Mg/dl
LIVER FUNCTION
1 SGOT 100 <38 U/L
2 SGPT 75 <41 U/L
IMMUNOSEROLOGY
1 Hs Troponin I 26,7 17-50 ng/l
ELECTROLYTE
1 Sodium 134 136-145 Mmol/l
2 Potassium 4,0 3,5-5,1 Mmol/l
3 Chloride 101 97-111 Mmol/l
ELECTROCARDIOGRAM (OKT 25TH ,2019)

Rhythm : Sinus Rhythm PR Interval : Normal, 0.16 secs

Heart Rate : 82 bpm QRS complex : QRS interval 0.06 secs,
Regularity : Regular S in V2 + R in V5 >35
Axis : Left Axis Deviation ST segment : Normal
P wave : Normal, 0.12 secs Twave : Normal
conclusion: SR, 82 bpm, LAD, LVH
ECHOCARDIOGRAM (OKT 25TH, 2019)

Conclusion :
• Normal left ventricle and right ventricle
systolic function, EF 58,0% (Biplane),
TAPSE 2,2 cm
• Concentric left ventricular hypertrophy
• Global normokinetik
• Mild Aorta regurgitation
• Mild left ventricle diastolic disfunction
THORAX X-RAY (OKT 25TH, 2019)
Conclusion :
• Cardiomegaly with lung congestion sign
• Dilatatio et elongatio aortae
• Right diafragma elevation
DIAGNOSIS
❑ Primary Diagnosis
▪ Unstable Angina Pectoris (UAP)
❑ Secondary Diagnosis
▪ Hypertensive heart disease
▪ Post appendectomy day 8
▪ Mild Hyponatremia
TREATMENT
▪ Natrium clorida 0,9% 500cc/24 hours/drips
▪ Clopidogrel 75 mg/24 hours/oral
▪ Aspilet 80 mg/24 hours/oral
▪ Nitroglycerin 10 mcg/menit/syringe pump
▪ Candesartan 16 mg/24 hours/oral
▪ Atorvastatin 40 mg/24 hours/oral
▪ Concor 2,5 ng/24 hours/oral
THANK YOU
 CASE
DISCUSSION
ACS DEFINITION
Acute coronary syndrome is a myocardial damage caused by
the imbalance of oxygen supply and demand for myocardial
tissue as the consequence of coronary artery occlusion either
because of total or partial occlusion as the result of atheroma
plaque rupture which is characterized by angina symptoms
(chest pain)

Management of Acute Coronary Syndromes Edited by Eli V. Gelfand and Christopher P. Cannon © 2009 John
Wiley & Sons Ltd.
RISK FACTOR

Modifiable Non-Modifiable
• Smoking • Age
• Diabetes Mellitus • Gender
• Dyslipidemia • Genetic
• Obesity
• Hypertension
• Physical inactivity
• Life style
PATHOPHYSIOLOGY
CLINICAL MANIFESTATION OF
UNSTABLE ANGINA PECTORIS
• A crescendo pattern in which patient with chronic stable angina
experiences a sudden increase in the frequency, duration, and or
intensity of ischemic episodes
• Episodes of angina that occur at rest without provocation
• New onset of anginal episodes describe as severe, without previous
symptomps of CAD
DIAGNOSIS

ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-
segment elevation. European Heart Journal (2011)
 TREATMENT
Anti-ischemia therapies :
• β-blocker
General measure :
•Nitrates
• +/- CCB •Pain control (morphine)
•Supplemental O2 if needed
Anti-thrombotic therapies :
Anti-platelet agents :
•Aspirin
•Clopidogrel (or prasurgel) Additional Therapy :
Anti-coagulants (use one) : •Statin
•LMWH (enoxaparin) •Angiotensin converting-enzyme
•Unfractionated intravenous heparin inhibitor
•Fondaparinux
THANK YOU