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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)
http://www.cardiosmart.org/HeartDisease
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
Cardiology, Desmond G. Julian, J.Campbell Cowan, James M. McLenachan, 8th edition, Elsevier, 2005
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
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.
Cardiology, Desmond G. Julian, J.Campbell Cowan, James M. McLenachan, 8th edition, Elsevier, 2005
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).
http://www.cardiosmart.org/HeartDisease
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
http://www.cardiosmart.org/HeartDisease
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