CASE PRESENTATION

Unstable Angina Pectoris High Risk +

Post ASD Closure
 Name : Mrs. R
No.MR : 605508
Age : 47 years old
Gender : Female
Date of admitted : March 28th 2013
Chief complaint: Chest pain

History taking:
It was felt since 2 weeks before admitted to the hospital. Pain
felt like pressed by heavy things. It was lasting more than 20
minutes and intermittent. The pain didnt trigger by activity and
not relieved by rest. The pain was followed by sweating (+), and
shortness of breath (+).

Epigastric pain (-), cough(-), fever (-), history of fever (-)

Defecation & urination is normal

 History of cardiac operation in 1993.

History of hypertension (-)

Diabetes (-)

Smoking (-)

Family history of heart disease (-)

General Appearance :
Moderate-illness /Normal weight/composmentis
Vital Sign :
Blood Pressure : 140/90 mmHg
Pulse : 84 x/minute, regular
Respiratory rate : 20 x/minute ; thoracoabdominal
Temperature : 36,6 C (per axilla)
Head Examination :
Eyes : anemia(-), icterus(-), cyanosis(-)
Neck : JVP R+1 cmH20
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 : Normal heart size
Auscultation : Regular of I/II Heart Sound,
murmur (-)
Abdominal Examination :
Inspection : Convex, following breath
movement
Palpation : Liver and spleen unpalpable
Percussion : Tympani
Auscultation : Peristaltic sound (+) , normal

Extremities :
Oedema (-)
EKG (28/3/2013)
Rhythm : Sinus Rhythm
QRS Rate : 56 bpm
PR interval : 0.12 sec
Axis : normoaxis
P Wave : 0,12 sec
QRS complex : 0,08 sec
ST segment :
Q wave :
V5-V6 :
Conclusion : Sinus bradikardi, HR 56x/ minute
- Extensive anterior et inferior ischaemic
Complete blood count Blood chemistry
WBC: 9.30x 103/ul CBG : 83 mg/dl
HGB: 14.2 gr/dl Ureum : 14 mg/dl
HCT: 42.2 % Creatinine : 0.7 mg/dl
PLT : 350 x103/l SGOT/SGPT: 20 / 19 u/dl

Electrolyte
Natrium : 140 mmol/l
Kalium : 4.2
Chloride : 103 mmol/l
Enzymes
CK : 68
CK-MB : 11 u/dl
Troponin T :-
Unstable Angina Pectoris High Risk +
Post ASD Closure
 O2 2-4 Lpm via NC

IVFD RL 10 dpm

Nitrate : ISDN Fasorbid (10mg/cc) 2mg/hour/SP

Anti-platelet aggregation :
Aspilet 80 mg 1-0-0
Plavix 75 mg 0-1-0

Anti-coagulant : Arixtra 2,5mg/24hrs/SC

Statin : Simvastatin 20mg (0-0-1)
Anti-anxiety : Alprazolam 0.5 mg (0-0-1)
Laxative: Laxadyne syr 0-0-2C
DISCUSSION
CAD
CAD

Stable
ACS Angina
Pectoris

UAP NSTEMI STEMI

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.
CLASSIFICATION
Based on CANADIAN CARDIOVASCULAR SOCIETY FUNCTIONAL
CLASSIFICATION

CLASS I No angina with ordinary activity. Angina with strenuous,

rapid or prolonged exertion.

CLASS II Slight limitation of ordinary activity ; angina when

walking up stairs briskly, or walking on a cold or windy day.

CLASS III Marked limitation ; angina when walking at normal

pace up flight of stairs, or walking 1-2 blocks distance.

CLASS IV Angina on minimal exertion or at rest.

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
 Causes of Unstable Angina
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
 RISK FACTOR

Modifiable :
Non-Modifiable :
- Smoking
- Family History of CVD
- Hypertension
- Age
- Dyslipidemia
- Gender
- Diabetes mellitus
- Obesity
DIAGNOSIS
Working Diagnose
 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
Clinical Manifestation
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
 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).

25
 MANAGEMENT
- Heparin - Nitrate 1. Medication
Stabilizing the plaque

Treating underlying
Relieve the symptom
- Clopidogrel (nitrogliseride) - Aspirin
- Lipid lowering agent
- Glikoprotein - Beta-blocker - CAD risk factor
treatment
IIb/IIIa - Calsium
2. Lifestyle
inhibitors channel modification
blocker - Healthy diet
- Exercise regular
- Quitting smoking
- Losing weight

http://www.cardiosmart.org/HeartDisease