UNSTABLE ANGINA PECTORIS

Name: Mahfuzah Hazirah STB: C 111 07 307 Supervisor: dr. Muzakkir Amir, SpJP.FIHA.FICA

PATIENTS 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. Nonradiated. 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 Moderate

STATE 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 BLOOD TEST WBC RBC HGB HCT PLT 5.54x10^3/uL 4.79x10^6/uL 14.1 g/dL 44.1% 244 x 10^3/uL Result Test Ureum Creatinine SGOT SGPT Trigliserida HDL LDL CARDIAC BIOMARKER CK CK-MB Troponin-T 415 u/L 13 u/L Negative ELEKTROLIT Natrium Potassium Cloride 145 mmol 35 mmol 104 mmol Result 30 mg/L 1.1 mg/L 30 U/L 14 U/L 94 62 226 CHEMICAL BLOOD TEST

RADIOLOGY FINDING
FOTO 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

DISCUSSION
UNSTABLE ANGINA PECTORIS

DEFINITION
Angina 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 MANIFESTATION
Unstable 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 FACTORS
Unstable angina results from coronary artery disease (CAD). Thus, risk factors for the development of CAD are also risk factors for unstable angina:
Smoking

Havinghigh cholesterollevels(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)
http://www.cardiosmart.org/HeartDisease

A 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.

Classification

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

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

DIAGNOSIS
Clinical

history: frequency and severity of the pain

Increase

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

 ECG ST

changes

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

Treatment for unstable angina focuses on three goals:

stabilizing

PRINCIPLE MANAGEMENT

any plaques that may have ruptured in order to prevent a heart attack, relieving symptoms treating the underlying coronary artery disease (CAD).

http://www.cardiosmart.org/HeartDisease

MANAGEMENT

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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)

http://www.cardiosmart.org/HeartDisease