Case Presentation

Unstable Angina Pectoris

By : Muhammad Junaid
Supervisor :
Prof. DR. dr. Ali Aspar Mappahya, Sp.PD,Sp.JP,FIHA, FACCS

Patient ID

Name : Mrs. N
Age : 60 years old
Address : Jln. Badaruddin dg.Lira
Medical Record : 251166
Date of Admittance : 14th April 2009

History Taking
Chief Complaint :Chest Pain
History Taking :

Experienced by the patient since 2 weeks ago and

worsen a few days before she was admitted to the
hospital. The pain was felt in the left chest and
referred to the left arm which characterized by pin
& needle feeling. The attacks lasted for 5 minutes
and later progressed up to 20 minutes. The
frequency increased from once a day to four times a
day. At first, the pain lessen with rest but now the
pain persists even while resting. Lately, she was
worried about her childrens problem. She
experienced no fever, no cough, no nausea, and no
vomiting. Patient also complaints of sleeping
difficulty. Micturity and defecation were normal.

Risk Factor

Female 60 years old (> 55 years old)

Hypertension (+) since age 32 years old.
Family history (-)
Smoking history (-)
Alcohol (-)
Obesity (-)
Diabetes Mellitus (-)
Dislipidemia (-)

Past Illness History

Diabetes mellitus (-)
Hypertension (+)
Heart disease (-)
Family history of heart disease (-)

Physical Examination
General Appearance :

Moderate-illnes/Normal weight/conscious

Vital Sign :

Pulse : 65 tpm
Blood Pressure : 180/100 mmHg
Inspiratory rate : 20 tpm
Body temperature : 36.6 C

Head Examination :

Eyes : no anemia, no jaundice, no cyanosis

Neck : JVP R-1 cmH20

Thoracic Examination :

Inspection : Symmetric sinistra et dextra

Palpation : no mass, no tenderness
Percussion : Sonor
Auscultation : Breath Sound was vesicular, no extra sound

Physical Examination
Cardiac Examination :
Inspection : Ictus Cordis wasnt visible
Palpation : Ictus Cordis wasnt palpable
Percussion : dullness
Auscultation : regular of I/II Heart Sound, no murmur

Abdominal Examination :
Inspection : Normal
Palpation : No mass palpable, No tenderness
Percussion : tympani
Auscultation : peristaltic sound (+), normal

Extremities :
No limbs edema

Laboratory Examination
Complete blood
WBC : 8,7 x 103 /mm3
HGB : 12,1 g/dl
HCT : 37,4 %
RBC : 3,93 x 106 /mm3
PLT : 356 x 103 /mm3

Cardiac enzyme
CK
: 67 (<167)
CK MB
: 17 (< 25)

Blood chemistry
Random blood sugar
SGOT
SGPT
Total Cholesterol
HDL
LDL
Triglyseride

: 167 mg/dl
: 19 u/l
: 14 u/l
: 208 mg/dl()
: 37 mg/dl()
: 137mg/dl ()
: 176 mg/dl

Electrocardiogram

Electrocardiogram

Sinus Rhythmic
Heart rate 65 bpm
Axis : Normoaxis
T inverted : lead 1,AVL, V1 V6
Iskemia Miokard Anteroseptolateral

Echocardiogram

Echocardiogram

Hypertension Heart Disease

Sistolic Function of Left Ventrikel
Normal
Diastolic Disfunction
Pulmonal Hypertension
EF 85 %

Suggestion examination
Thorax radiography
Coronary angiography

Diagnosis
Unstable Angina Pectoris
Hypertension Grade II

Management

Cardiac Diet
O2 3 4 Lpm
IVFD NaCl 0,9 % 12 dpm
Nitroglicerin 10 g/mnt
Plavix (clopidogrel) 75 mg 1x4 1x1
Aspilet (aspirin) 80 mg 1x2 1x1
Captopril (ACE inhibitor) 25 mg 2x1
Simvastatin 20 mg 0-0-1
Alprazolam 0,5 mg 0-0-1
Laxadine syr 3 x 1 cc

Discussion
Unstable Angina Pectoris

Definition
Angina pectoris is a syndrome characterized by
chest pain resulting from an imbalance between
oxygen supply and demand, and is most
commonly caused by the inability of atherosclerotic
coronary arteries to perfuse the heart under
conditions of increased myocardial oxygen
consumption.
Classification of Angina Pectoris :
- Stable angina
- Unstable angina

 Stable angina is the most common angina, and the type

most people mean when they refer to angina.
Stable Angina
People with stable angina usually have angina symptoms
on a regular basis. The episodes occur in a pattern and are
predictable.
For most people, angina symptoms occur after short bursts
of exertion.
Stable angina symptoms usually last less than five minutes.
They are usually relieved by rest or medication, such as
nitroglycerin under the tongue.

Unstable Angina
Unstable angina is less common. Angina symptoms
are unpredictable and often occur at rest.
This may indicate a worsening of stable angina, but
sometimes the first time a person has angina it is
already unstable.
The symptoms are worse in unstable angina - the
pains are more frequent, more severe, last longer,
occur at rest, and are not relieved by nitroglycerin
under the tongue.

Pathophysiology

Risk Factors

Hypertension
High levels of cholesterol and other fats in the blood
Diabetes
Smoking
Male gender or female > 55 years old
Inactive (sedentary) lifestyle
Family history of coronary heart disease
Aging
Regular use of stimulants, especially nicotine, cocaine,
or amphetamines: Other stimulants include
theophyllines, inhaled beta-agonists, caffeine, diet pills,
and decongestants.

Diagnose
Signs of myocardial ischemia
ECG
ST segmen elevation ?

No

Acute Myocardial Infarction

( Q-wave, non-Q wave )

Lab

Biochemical cardiac markers ?

No

Yes

Yes

NSTEMI
( No ST-Segment
Elevation
Myocardial Infarction )

Unstable Angina

Treatment

Bed rest
Diet & Modification of risk factors (smoking, BP, lipids)
Oxygen
Nitroglycerin
Antiplatelet drugs ( aspirin plus clopidogrel )
-Blockers
Ca channel blockers
ACE inhibitors

Statins
Revascularization : PCI (eg, angioplasty, stenting) or CABG

Management

Bed rest
Diet
Oxygen
Nitroglycerin:
Beta blockers: Beta blockers lessen the heart's workload. They slow the heart rate,
decrease blood pressure, and lessen the force of contraction of the heart muscle. This
decreases the heart's need for oxygen and thus decreases angina symptoms. Beta blockers
are taken every day, regardless of whether the patient is having symptoms, because they
are proven to prevent heart attacks and sudden death.

Clopidogrel

Calcium channel blockers (CCBs): Calcium channel blockers are used primarily when
beta blockers cannot be used and/or the patient is still having angina with beta blockers.
Calcium channel blockers also lower blood pressure and certain ones slow heart rate.
Calcium channel blockers have to be taken every day.
Aspirin
Statins: Statins lower cholesterol and have been shown to stabilize the fatty plaque on the
inner lining of the coronary artery, even when the blood cholesterol is normal or minimally
increased. Low density lipoprotein (LDL) or "bad cholesterol" levels should be less than 70
mg/dL for those at high risk of heart disease. Every person with angina needs to know
exactly what his or her blood lipids/fats are.
Miscellaneous anti-anginal drugs : In 2006, the FDA approved ranolazine (Ranexa)
indicated only after other conventional drug treatments are found to be ineffective.

Glycoprotein IIb/IIIa antagonists

ACE inhibitor

Surgical Care
: Percutaneus coronary intervention (PCI)

& coronary artery bypass graft (CABG)