UNSTABLE ANGINA PECTORIS

Presented by :
Andi riskayani
C111 09 345

Supervisor :
Prof. dr. Peter Kabo Ph.D, Sp.FK, Sp.JP(K), FIHA, FASCC
Department of Cardiology and Vascular Medicine
Faculty of Medicine Hasanuddin University
Makassar
2014

PATIENTS IDENTITY
Name
Gender
Age
RM
Date of Admission

: Mr. AR
: Male
: 63 years old
: 68-25-19
: October 1st,2014

History Taking
Chief Complaint : Chest pain
Guided Anamnesis:
Chest pain felt since 7 hours before admitted to the hospital. It felt
like a heavy-weight pressure at substernal area, passes to the back
and it radiates to the left arm. The duration was about 30 min.
Symptoms are triggered by activities and doesnt relieve by resting.
It is usually accompanied by cold sweating. History of chest pain
before (+) about 7 months ago, sometimes feels better after resting.
History of syncope (-). History of shortness of breath (-), paroxysmal
nocturnal dispneu (-), ortopneu (-). No nausea and vomit. Epigastric
pain (+), history of epigastric pain (-). Urination and defecation
remains normal.

Past Illness History

History of hypertension (+) since 5 years ago,
consuming anti-hypertension drugs, non-adherent.
History of smoking (+) since 20 years ago,
approximately 1 pack for 3 days.
History of DM (-).
History of dyslipidemia unknown.
Family history of cardiovascular disease denied.

Risk Factors
Modifiable
Hypertension
Smoking
Obesity

Non modifiable
Male , 63 years old
History of chest pain in
the past

Clinical Examination
GENERAL STATE
Moderate illness/overweight/compos mentis
BMI : 26,59 kg/m2 (obes 1)
VITAL SIGN
- Blood pressure : 140/90 mmHg
- Pulse
: 72 beats/min
- Breathing
: 20 times/min
- Temperature : 36,6 0 C (Axilla)

Head Examination
Eyes : anemia -/-, icterus -/-,
Lip : cyanosis (-)
Neck : JVP R+2 cmH2O (30 degree)
Chest Examination

Inspection : symmetric R=L, normochest

Palpation
: mass (-), tenderness (-),
vocal fremitus right = left

Percussion : sonor left and right

Auscultation : breath sound : vesicular

additional sound : ronchi -/wheezing -/-

Cardiac Examination
Inspection : IC is not visible
Palpation
: IC is not palpable
Percussion : Right heart border in right
parasternal line, left heart
border in left anterior axilla line,
top heart border in left intercostal
II
Auscultation : Regular S1/S2 heart sound,
murmur (-)

Abdominal Examination
Inspection
: Flat and follows with
breath movement
Auscultation : Peristaltic sound (+)
Palpation
: Liver and spleen not
palpable
Percussion
: Timpany (+)
Extremities
- Oedema

: Pretibial -/Dorsum pedis -/-

ELECTROCARDIOGRAPHY

ELECTROCARDIOGRAPHY

INTERPRETATION

Rhythm
P wave
Heart Rate
PR interval
Axis
QRS complex
ST Segment
T wave

: Sinus
: 0,08 s
: 72 x/min
: 0,16 s
: Normoaxis
: 0,08 s
: isoelectric
: T inverted on lead I, aVL, V1-V4

Conclutions:
Sinus rhythm normal rate, Normoaxis, Anteroseptal ischemic

LABORATORY FINDINGS
TEST

RESULT

NORMAL VALUE

WBC

9,5 x 103 /mm3

4,0-10,0 x 103/ mm3

RBC

4,25 x 106 /mm3

4,0-6,0 x 106/ mm3

Hb

14,2 mg/dl

13,0-17,0g/dl

Hct

39,0 %

40,0-54,0 %

GDS

141 mg/dl

140 mg/dl

Ureum

39 mg/dl

10-50 mg/dl

Creatinin

1,0 mg/dl

M(<1,3);F(<1,1) mg/dl

PLT

228 x 103 /uL

150-500 x 103/l

TEST

RESULT

NORMAL VALUE

CK

167 U/L

L(<190) P (<167)

CK-MB

19,8 U/L

< 25

Troponin T

<0,02

<0,05 ng/ml

SGOT

30 mg/dl

<38 U/l

SGPT

25 mg/dl

<41 U/l

Total Cholesterol

223 mg/dl

200 mg/dl

HDL

51 mg/dl

M(>55);F(>65) mg/dl

LDL

144 mg/dl

<130 mg/dl

TG

147 mg/dl

200 mg/dl

9,4 mg/dl

2,4-5,7 mg/dl

Uric Acid

CHEST X-RAY PA
Cardiomegaly, CTI : 0,6
Dilatatio et elongatio
aortae

WORKING DIAGNOSIS
Unstable Angina Pectoris

 Bed rest
O2 2-4 LPM via Nasal Canule
IVFD NaCl 0,9% 500 cc/24 hrs
Nitrate : ISDN Fasorbid 10 mg/8 hr/oral

Fasorbid 5 mg/sublingual
Anti-platelet aggregation :
Aspilet 80 mg 1x1
Clopidogrel 75 mg 1x1
Anti-coagulant : Arixtra 2,5mg/24hrs/SC
Anti-Hypertension : Candesartan 16mg/24hrs/oral
Statin : Simvastatin 20 mg (0-0-1)
Anti-anxiety : Alprazolam 0.5 mg (0-0-1)
Laxative: Laxadine syr 0-0-2 cth

Acute Coronary Syndrome

Unstable Angina Pectoris

ACUTE CORONARY SYNDROME ?

Spectrum of disease related to myocardial ischemia

ACUTE
CORONARY
SYNDROME

STEMI

NSTEMI

UNSTABLE
ANGINA
PECTORIS

ACUTE CORONARY SYNDROME

Pathogenesis of Acute
Coronary Syndromes:
Plaque
Fissure or
Rupture

The integral role of

platelets
Platelet
Adhesion
Platelet
Activation
Platelet
Aggregation
Thrombotic
Occlusion

ACUTE CORONARY SYNDROME

Supply

Imbala
nce

Demand

RISK FACTOR

Non-modifiable
Age
Gender
Family History of Heart
Disease

Modifiable

Smoking
Dislipidemia
Hypertension
Diabetes mellitus
Lack of exercise
Obesity

DIAGNOSIS ?

ANAMNESIS
Prolonged pain (usually >20
mins) constricting, crushing,
squeezing
Usually retrosternal location,

radiating to left chest, left arm,

can be epigastric
Dyspnea
Palpitations
Nausea/vomiting

UNSTABLE ANGINA
Occurring at rest (or with
minimal exertion) and
usually lasting more than 20
minutes (if not interrupted
by nitroglycerin)
Being severe and described
as frank pain and of new
onset (i.e., within 1 month)
Occurring with a crescendo
pattern (i.e., more severe,
prolonged, or frequent than
previously

EKG

LABORAT
ORIUM

DIAGNOSIS
ECG
Yes

No

Lab
Yes

No

Unstable Angina
Therapeutic Goals

Stabilize
plaque

Relieving
symptoms

Treating
underlying
32

THANK YOU