CASE REPORT

UNSTABLE ANGINA PECTORIS

Muh. Rakib Yunus (C014182009)

Supervisor : dr. Akhtar Fajar M, Sp.JP., FIHA

Patient's Identity
■ Name : Mr. P
■ Age : 65 yo
■ Address : Makassar
■ Admitted on : February 4th, 2019
■ MR : 872267
ANAMNESIS
❑ Chief Complain : Chest pain
❑ Recent Disease History
▪ Chest pain was felt since 3 days ago before admitted to the
hospital. Pain worsened at night and last night was the most
painful chest pain (18 hours before patient went to the hospital)
▪ Stabbing chest pain but didn't radiated to the left arm
▪ Chest pain lasts for >20 minutes
▪ There were no history of nausea and vomitting
ANEMNESIS
❑ Past Disease History
▪ There was a history of chest pain
▪ History of being hospitalized with coronary artery disease
▪ There was a history of hypertension and didn't take the
medicine regularly
▪ There was no history of diabetes mellitus
ANEMNESIS
❑ Familial History
▪ There was no familial history of CAD
▪ There was no familial history of hypertension
▪ There was no familial history of diabetes mellitus
❑ Habitual History
▪ Eating fatty food
▪ Not smoking
▪ Not drinking alcohol
RISK FACTORS
❑ Modifiable Risk Factors
▪ Eating fatty food
▪ Hypertension
❑ Unmodifiable Risk Factors
▪ Gender (Male)
▪ Age (65 years old)
PHYSICAL EXAMINATION
❑ General Status
▪ Moderately ill/Normal nutrition/Compos mentis (E4M6V5)
▪ Weight : 66 kg
▪ Height : 173 cm
▪ Body Mass Index : 22,07 kg/m2 (Normal)
❑ Vital Signs
▪ Blood Pressure : 130/80 mmHg
▪ Heart Rate : 100 bpm/regular
▪ Respiratory Rate : 24 bpm
▪ Temperature : 36.4ºC
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+3cm 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 (-)
▪ Auscultation : Peristaltic (+)
▪ Palpation : There were no tumor mass, tenderness, and hepar-lien
enlargement
▪ Percussion : Tympany (+)
❑ Extremity Examination : Cold acral, oedema (-), CRT <2 seconds, ulcus (-)
No Examination Result Reference Unit
HEMATOLOGY
Routine Hematology
1 WBC 6,41 4,00-10,0 10^3/ul
2 RBC 3,92 4,00-6,00 10^6/ul
3 HGB 13,7 12,0-16,0 gr/dl Laboratorium
4 HCT
5 MCV
39,3
100,3
37,0-48,0
80,0-97,0
%
fL
(February, 4th
6 MCH 34,9 26,5-33,5 pg 2019)
7 MCHC 34,9 31,5-35,0 gr/dl
8 PLT 162 150-400 10^3/ul
Coagulation
1 PT 9,8 10-14 seconds
2 INR 0,94 --
3 APTT 27,8 22,0-30,0 seconds
 BLOOD CHEMISTRY
Glucose
1 GDS 102 140 Mg/dl
2 Uric acid 5,5 P(2,4-5,7) L(1,4-7,0) Mg/dl
LIPID FRACTION Laboratorium
1 Total Cholesterol 146 200 Mg/dl
(February, 4th
2 HDL Cholesterol
2019)
45 L (> 55), P (> 65) Mg/dl

3 LDL Cholesterol 114 < 130 Mg/dl

4 Triglyceride 90 200 Mg/dl
KIDNEY FUNCTION
1 Ureum 24 10-50 Mg/dl
2 Creatinine 0,77 L (<1,3); P( <1,1) Mg/dl
 LIVER FUNCTION
1 SGOT 13 <38 U/L
2 SGPT 12 <41 U/L
Heart Biomarker
1 CK 134,07 L(<190);P(<167) U/L
2 CK-MB 13,2 <25 U/L
Laboratorium
IMMUNOSEROLOGY (February, 4th
Other Immunoserology
2019)
1 Troponin I <0,01 <0,01 Ng/ml
Electrolyte
1 Sodium 139 136-145 Mmol/l
2 Potassium 3,9 3,5-5,1 Mmol/l
3 Chloride 103 97-111 Mmol/l
ELECTROCARDIOGRAM (Feb 4th,2019)

Rhythm : Sinus Rhythm PR Interval : Normal, 0.16 secs

Heart Rate : 97 bpm Q wave: Pathologic Q in lead II, III, aVF
Regularity : Regular QRS complex : Normal, 0.06 secs
Axis : Left Axis Deviation ST segment : ST depression in lead I, aVL, V2-6
P wave : Normal, 0.08 secs T wave : T inverted in lead V1-5
Conclusion : Old Myocardium Infarct Inferior
ECHOCARDIOGRAM (Feb 7th, 2019)

Conclusion :
• Normal left ventricle systolic function, EF
42,8%
• Concentric left ventricular hypertrophy
• Segmental hypokinesis
• Mild mitral regurgitation
• Mild left ventricle diastolic dysfunction
DIAGNOSIS
❑ Primary Diagnosis
▪ Unstable Angina Pectoris (UAP)
❑ Secondary Diagnosis
▪ Congestive Heart Failure
▪ Hypertension Heart Disease
TREATMENT
▪ Loading dose : Aspilet 160 mg and Clopidogrel 300 mg
▪ Clopidogrel 75 mg/24 hours/oral
▪ Aspilet 80 mg/24 hours/oral
▪ Isosorbide dinitrat 5 mg/if chest pain/sublingual
▪ Farsorbid 10 mg/8 hours/oral
▪ Atorvastatin 40 mg/24 hours/oral
▪ Furosemide 40 mg/24 hours/oral
▪ Alprazolam 0,5 mg/24 hours/oral
▪ Laxadine emulsion 10 ml/24 hours
▪ Captopril 25 mg/8 hours/oral
PLANNING
▪ Angiography Coroner
▪ PCI
GRACE SCORE ASSESSMENT
In-hospital Risk Score
Age 65 years old 55
Heart Rate 97 bpm 13
Systolic Blood Pressure 130 mmHg 37
Creatinine 0,77 3
KILLIP : II 21
Cardiac Arrest in the hospital (-) 0
Elevated Heart Biomarker (-) 0
Depressed ST-segment 30

GRACE SCORE : 159 (High Risk, Probability of death in-hospital >3%)

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.
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
muh.rakibyunus@unhas.web.id