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Unstable Angina Pectoris
Mr. I, a 64-year-old male, presented to the hospital with chest pain. He reported feeling pressure and tightness in his chest for the past 5 months that had worsened. Examinations found elevated blood pressure, tachycardia, and signs of cardiomegaly on chest x-ray. ECG showed sinus rhythm with poor R wave progression. Echocardiogram indicated left ventricular dysfunction. The working diagnosis was unstable angina pectoris and hypertension. Management included medications to reduce blood pressure and prevent clots, with monitoring through daily ECGs.
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Unstable Angina Pectoris
- 1. CASE REPORT CARDIOLOGYDEPARTMENT 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 - CASEREPORT CARDIOLOGY DEPARTMENT PATIENT’S IDENTITY Name : Mr. I Gender : Male Umur : 64 y.o Reg. Number : 595424 Admitted Date : 25th, April 2013
- 3. UAP - CASEREPORT 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 - CASEREPORT 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 - CASEREPORT 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 - CASEREPORT 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 - CASEREPORT 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 >55y. 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
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- 10. UAP - CASEREPORT 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 - CASEREPORT 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 WALLMOTION, 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 - CASEREPORT CARDIOLOGY DEPARTMENT WORKING DIAGNOSIS UNSTABLE ANGINA PECTORIS & HYPERTENSION GR.I
- 14. UAP - CASEREPORT 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 - CASEREPORT CARDIOLOGY DEPARTMENT PLANNING ECG / day
- 16. UAP - CASEREPORT CARDIOLOGY DEPARTMENT DISCUSSION UAP
- 17. UAP - CASEREPORT 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 - CASEREPORT 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 - CASEREPORT 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 - CASEREPORT 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 - CASEREPORT 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 - CASEREPORT 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 - CASEREPORT 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 - CASEREPORT 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 - CASEREPORT 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
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- 27. UAP - CASEREPORT CARDIOLOGY DEPARTMENT CORONARY ARTERY DISEASE UAP ACS NSTEMI Stable Angina Pectoris STEMI CAD
- 28. UAP - CASEREPORT 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 ofClinical Medicine 6th
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- 32. UAP - CASEREPORT 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 - CASEREPORT 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 - CASEREPORT 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/ischemiaat 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) Patientor physician preference in the absence of high-risk features
- 38. UAP - CASEREPORT CARDIOLOGY DEPARTMENT MANAGEMENT http://www.cardiosmart.org/HeartDisease
- 39. UAP - CASEREPORT CARDIOLOGY DEPARTMENT THANK YOU dr. Muzakkir Amir, Sp.JP, FIHA, FICA