Cardiology Department

1. CASE REPORT CARDIOLOGY DEPARTMENT
UNSTABLE
ANGINA PECTORIS (UAP)
Presented by:
Faradhillah A Suryadi
C11108340
Supervisor:
dr. Muzakkir Amir, SP.JP, FIHA. FICA.
CARDIOLOGY DEPARTMENT
MEDICAL FACULTY
MAKASSAR
2013

2. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
PATIENT’S IDENTITY
 Name
: Mr. I
 Gender
: Male
 Umur
: 64 y.o
 Reg. Number
: 595424
 Admitted Date : 25th, April 2013

3. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
HISTORY TAKING
 Chief
Complaint : Chest pain
 Structural anamnesis
It 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 (-)

4. 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

5. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
PHYSICAL EXAMINATION
 General
Appearance :
Moderate-illness /Malnutrition/composmentis
 Vital Sign
 BP
 Pulse
 RR
 Temp
:
: 150/100 mmHg
: 108 x/minute, regular
: 28 x/minute ;
: 36,7º C (per axilla)
 Head Examination :
 Eyes : anemia(-), icterus(-),
 Neck : JVP R+1 cmH20
cyanosis(-)

6. 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 (-)

7. 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 (-)

8. 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

9. ECG 25/4/13
ECG (25/4/2013)

10. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
ECG INTERPRETATION
Rhythm
: Sinus Rhythm
QRS Rate
: 89 bpm
PR interval
: 0.12 sec
Axis
: normoaxis
P Wave
: 0,12 sec
QRS complex : 0,08 sec
ST segment : normal
Conclusion : Sinus rhytm, HR 89x/ minute
normoaxis, poor R wave progression
-

11. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
LABORATORY FINDINGS
Complete Blood Count
WBC : 9,48x103 uL
HB: 13,2 g/dl
HCT : 38,9%
PLT : 290x103 uL

Electrolyte
Natrium : 145
Kalium : 3,44
Chloride : 105

Enzymes
CK : 43 u/L
CK-MB : 10,5 u/L
Troponin T : negatif

Blood chemistry
SGOT : 18
SGPT : 16
Ureum : 31
Creatinin : 0,5
Uric acid : 7,3
Glucose :120 mg/dl

Lipid Profile
Trigliserida : 209
LDL : 154
HDL : 30
Total Cholesterol : 204


12. ECHOCARDIOGRAM
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

13. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
WORKING DIAGNOSIS
UNSTABLE ANGINA PECTORIS
&
HYPERTENSION GR.I

14. 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 0-1-0
Clopidogrel (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
•
•
•
•

15. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
PLANNING
 ECG
/ day

16. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
DISCUSSION
UAP

17. 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.

18. PATHOGENESIS
UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
 Plaque
rupture
 Thrombus formation
 Incomplete/ intermittent
occlusion of the infactrelated 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

19. 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, adhesion, and aggregation of
platelets and the activation of the
clotting cascade, resulting in the
formation of an occlusive
thrombus. If this process leads to
complete occlusion of the
artery, then acute myocardial
infarction with ST-segment
elevation occurs. Alternatively, if
the process leads to severe
stenosis but the artery nonetheless
remains patent, then
unstable angina occurs.

20. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
CAUSES
 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

21. 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

22. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
UAP
If 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

23. 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

24. BRAUNWALD
CLASSIFICATION
Characteristic
Severity
UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
Class/Category
Details
Subacute symptoms at rest (2-30 d prior)
III
Acute symptoms at rest (within prior 48 h)
A
Secondary
B
Primary
C
Postinfarction
1
No treatment
2
Usual angina therapy
3
Therapy during symptoms
Symptoms with exertion
II
Clinical precipitating factor
I
Maximal therapy
Tan, A Walter. Unsta ble Angina Pectoris Clinical Presentation (updated 7th Dec 2011)
http://emedicine.medscape.com/article/159383-overview#showall

25. 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

26. ACS RISK ASSESMENT

27. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
CORONARY ARTERY
DISEASE
UAP
ACS
NSTEMI
Stable Angina
Pectoris
STEMI
CAD

28. 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.

29. DIAGNOSIS
Oxford Handbook of Clinical Medicine 6th

30. DIAGNOSIS
ECG
Yes
No
Lab
Yes
No

31. PROGNOSIS

32. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
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 ECG
The 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

33. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
RISK FACTORS
Modifiable:
Non-modifiable:
 Hypertension

 Diabetes

Mellitus
 Dyslipidemia
 Smoking
 Obesity


Gender: male
Age >45 years old
Personal history of
Coronary Artery
Disease
Family history of
Coronary Artery
Disease

34. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
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).
34

35. Yeghazartan, Y., Braunstein, J., Stone, P. Unstable Angina Pectoris (review article) NEJM Vol.342(2):101114. January, 2000. Massachusets Medical Society

36. Patient Characteristics
Recurrent angina/ischemia at
rest or with low-level activities
despite intensive medical
therapy
Elevated cardiac biomarkers (TnT
or TnI)
New or presumably new STsegment depression
Signs or symptoms of heart failure
or new or worsening mitral
regurgitation
High-risk findings on noninvasive
stress testing
High-risk score (eg, TIMI, GRACE)
Reduced LV systolic function
(LVEF less than 40%)
Hemodynamic instability
Sustained ventricular
tachycardia
PCI within 6 months
Previous CABG

37. Conservative
Low-risk score
(eg, TIMI,
GRACE)
Patient or
physician
preference in
the absence
of high-risk
features

38. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
MANAGEMENT
http://www.cardiosmart.org/HeartDisease

39. UAP - CASE REPORT
CARDIOLOGY DEPARTMENT
THANK YOU
 dr.
Muzakkir Amir, Sp.JP, FIHA, FICA