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UNSTABLE ANGINA PECTORIS (UAP)
Supervisor:
dr. Muzakkir Amir, SP.JP, FIHA. FICA.
CARDIOLOGY DEPARTMENTMEDICAL FACULTY
MAKASSAR2013
Presented by:
Faradhillah A Suryadi C11108340
CASE REPORT CARDIOLOGY DEPARTMENT
PATIENT’S IDENTITY Name : Mr. I Gender : Male Umur : 64 y.o Reg. Number : 595424 Admitted Date : 25th, April 2013
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
HISTORY TAKING
Chief Complaint : Chest pain Structural anamnesisIt was felt since 2 hours before admitted to the hospital. The pain was felt in right chest then radiated to the left chest, with the characteristic of pressure sensation. Pain was last more than 20 minutes. Chest pain accompanied by shortness of breath and sweating (+). The patient complaint about tightness while walking since 5 months ago, which became worse, and it was not relieved by rest. DOE (+) PND (-) orthopneu (-)
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
PAST MEDICAL HISTORY History of hypertension (-) History of Diabetes (-) History of chest pain (-) Family History of having CVD (-) History of Smoking (+) ± 30 years, 1
pack/day and stop since last 2 years
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
PHYSICAL EXAMINATION General Appearance :
Moderate-illness /Malnutrition/composmentis Vital Sign :
BP : 150/100 mmHg Pulse : 108 x/minute, regular RR : 28 x/minute ; Temp: 36,7º C (per axilla)
Head Examination : Eyes : anemia(-), icterus(-), cyanosis(-) Neck : JVP R+1 cmH20
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
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 dextra Auscultation : Regular of I/II Heart Sound,
murmur (-) gallop (-)
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
Abdominal Examination : Inspection : Convex, following breath
movement Palpation : Liver and spleen
unpalpable Percussion : Tympani Auscultation: Peristaltic sound (+), normal
Extremities : Oedema (-)
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
CHEST X-RAY
Male >55 y. o Cigarette Smoking Dislipidemia Hypertension
Dilatation of blood vessels in both suprahili lungs and dilatation of right hilus
Enlargement of the cardiac with CTI 15/22=0.68, stretched cardiac waist , embedded apex, normal aorta
Both sinus and diaphragm in good conditions.
Bones are intact.
Conclusion: Cardiomegaly with signs of
congestive lungs
ECG (25/4/2013)
ECG 25/4/13
ECG INTERPRETATIONRhythm : Sinus RhythmQRS Rate : 89 bpmPR interval : 0.12 secAxis : normoaxis P Wave : 0,12 secQRS complex : 0,08 secST segment : normalConclusion : Sinus rhytm, HR 89x/ minute
normoaxis, poor R wave progression-
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
LABORATORY FINDINGS Complete Blood CountWBC : 9,48x103 uLHB: 13,2 g/dlHCT : 38,9%PLT : 290x103 uL
ElectrolyteNatrium : 145Kalium : 3,44Chloride : 105
EnzymesCK : 43 u/LCK-MB : 10,5 u/LTroponin T : negatif
Blood chemistrySGOT : 18SGPT : 16Ureum : 31Creatinin : 0,5Uric acid : 7,3Glucose :120 mg/dl
Lipid ProfileTrigliserida : 209LDL : 154HDL : 30Total Cholesterol : 204
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
DESCRIPTION OF WALL MOTION, MASSES, VALVES, PERICARDIUM
Conclusion : • LV sistolic and diastolic dysfunction• Akinetic basal mid septal, anterior septal, other segment hipokinetic• MR Mild• AR Mild• TR Mild• PR Mild• PH Moderate
ECHOCARDIOGRAM
WORKING DIAGNOSISUNSTABLE ANGINA
PECTORIS&
HYPERTENSION GR.I
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
MANAGEMENT• O2 2-4 LPM via Nasal Canule• IVFD NaCl 0,9% 12 dpm• Nitrate : ISDN Fasorbid (10mg/cc) 2mg/hour/SP• Anti-platelet aggregation :
Aspilet 80 mg 0-1-0Clopidogrel (Plavix) 75 mg 1-0-0
• Anti-coagulant : Arixtra 2,5mg/24hrs/SC• Anti hipertensi : ACE – I : captopryl 25 mg 1-1-1• Statin : Simvastatin 20mg (0-0-1)• Anti-anxiety : Alprazolam 0.5 mg (0-0-1) p.r.n• Laxative: Laxadyne syr 0-0-2C
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
PLANNING ECG / day
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
DISCUSSION
UAP
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.
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
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
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, ad-hesion, and aggregation of platelets and the activation of the clotting cascade, resulting in the formation of an occlusivethrombus. If this process leads to complete occlusion of the artery, then acute myocardial infarction with ST-segmentelevation occurs. Alternatively, if the process leads to severe stenosis but the artery nonetheless remains patent, thenunstable angina occurs.
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
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
CAUSES
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
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
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
UAPIf 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
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
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
CharacteristicClass/
CategoryDetails
Severity I Symptoms with exertion
II Subacute symptoms at rest (2-30 d prior)
III Acute symptoms at rest (within prior 48 h)
Clinical precipitating factor A Secondary
B Primary
C Postinfarction
Therapy during symptoms 1 No treatment
2 Usual angina therapy
3 Maximal therapy
BRAUNWALD CLASSIFICATION
Tan, A Walter. Unsta ble Angina Pectoris Clinical Presentation (updated 7th Dec 2011) http://emedicine.medscape.com/article/159383-overview#showall
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
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
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
ACS RISK ASSESMENT
CORONARY ARTERY DISEASE
CAD
ACS
UAP
NSTEMI
STEMIStable Angina Pectoris
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.
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
DIAGNOSIS
Oxford Handbook of Clinical Medicine 6th Edition
WHO Diagnostic Criteria
Clinical history of ischemic type chest
pain lasting for more than 20
minutes
Changes in serial ECG tracings
Rise and fall of serum cardiac
biomarkers such as creatine kinase-MB
fraction and troponin
No
Yes
Yes
No
ST-elevation Myocardial Infarction
NSTEMI( Non ST-Elevation
Myocardial Infarction )
Unstable Angina
Signs of myocardial ischemia
↑ Biochemical cardiac markers ?
ECG
Lab
ST segment elevation?
DIAGNOSIS
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 ECGThe 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
PROGNOSIS
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
RISK FACTORS
Modifiable: Hypertension Diabetes
Mellitus Dyslipidemia Smoking Obesity
Non-modifiable: Gender: male Age >45 years old Personal history of
Coronary Artery Disease
Family history of Coronary Artery Disease
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
34
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).
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
Yeghazartan, Y., Braunstein, J., Stone, P. Unstable Angina Pectoris (review article) NEJM Vol.342(2):101-114. January, 2000. Massachusets Medical Society
Patient CharacteristicsRecurrent angina/ischemia at rest or with low-level activities despite intensive medical therapyElevated cardiac biomarkers (TnT or TnI)
New or presumably new ST-segment depression
Signs or symptoms of heart failure or new or worsening mitral regurgitationHigh-risk findings on noninvasive stress testing
High-risk score (eg, TIMI, GRACE)Reduced LV systolic function (LVEF less than 40%)
Hemodynamic instability
Sustained ventricular tachycardiaPCI within 6 months
Previous CABG
Conservative Low-risk score (eg, TIMI, GRACE)
Patient or physician preference in the absence of high-risk features
MANAGEMENT
http://www.cardiosmart.org/HeartDisease
UAP - CASE REPORT CARDIOLOGY DEPARTMENT
THANK YOU dr. Muzakkir Amir, Sp.JP, FIHA, FICA
UAP - CASE REPORT CARDIOLOGY DEPARTMENT