1) The document describes unstable angina, which results from a thrombus developing on an atherosclerotic plaque, causing ischemia. It involves worsening chest pain at rest or with less exertion than previously tolerated that is not relieved by nitroglycerin. 2) Risk factors for unstable angina include smoking, diabetes, hypertension, family history, and obesity. Diagnosis involves ECG, which may show transient ischemia, and cardiac enzymes which are normal. 3) Management involves MONA therapy (morphine, oxygen, nitrates, aspirin) as well as beta blockers or calcium channel blockers for rate and rhythm control.

1. Name: Mohammad Noorani
Group: 5020
Rework: Unstable angina

2. Literature review
Unstable angina:
•Worsening of previously stable angina, chest
pain at rest, or pain not relieved
with nitroglycerin, in the absence of elevated
troponin levels
• Belongs to the spectrum of acute coronary
syndrome

3. Editology:
Angina results from coronary
artery disease (CAD):
•CAD may be microvascular or macrovascular, with
atherosclerotic narrowing of
coronary arteries and arterioles.
•Unstable angina is due to a thrombus that
develops on an atherosclerotic plaque,
causing ischemia (decreased blood flow).

4. Risk factors:
Cardiac risk factors include:
•Smoking
•Diabetes
•Hypertension
•Family history
•Obesity

5. Pathogenesis of angina:
Ischemia results when oxygen demand is
greater than supply:
•Results in myocardial ischemia → acidosis and ↓
formation of ATP.
•Loss of integrity of the myocardial membrane
→ release of chemical substances that stimulate
nerve.
•cells within cardiac muscle and around coronary
vessels.

6. Clinical picture:
•Acute presentation
•Chest pain that lasts 10–30 minutes (or more)
•Occurs at rest or with previously tolerated levels
of exertion
•No predictable pattern
•Not relieved with rest or nitroglycerin

7. Physical Examination:
•Patients with unstable angina may have any (or
none) of these findings:
•↑ BP
•↑ HR
•S3 or S4 heart sounds
•New mitral regurgitation murmur
•Change in intensity of existing murmurs

8. Diagnosis
Initial evaluation:
• ECG:
• Done during an episode of chest pain
• May be normal (or show nonspecific changes) in both types of angina
• May show transient evidence of subendocardial ischemia:
• ST-segment depression
• T-wave flattening
• T-wave inversion
• Lab tests: cardiac enzymes (e.g., troponin) are normal in stable and
unstable angina.
• Chest X-ray: often ordered to evaluate for other causes of chest pain

9. Advance Imaging:
•Coronary CT angiography may be used
in patients who cannot undergo stress testing.
•Cardiac angiography is indicated for unstable
patients or after abnormal stress testing:
•Gold standard
•Evaluates for occlusion in the major
coronary arteries

10. Management:
•Mona therapy-Morphine, oxygen therapy,
Nitrates, Aspirin
•For rate and rhythm control- Beta blocker, CCB

11. Case review:
Patient ID
Name-alexi
Age-58
Sex-Male
Occupation- retired teacher
Anamnesis morbi:
• 58 Year old patient comes to the emergency department
with complaints of severe chest pain radiating to the neck
jaw and arm not relieved by rest.symptoms suddenly appear
when patient watching TV

12. Patient history-He is a chronic smoker smoke 1.5 packet/day
from last 10 years And also drink alcohol
Family history- His father had DM and mother died Due to MI
Chief complaints:
Substernal chest pain or discomfort:
• Described as “pressure”
• May radiate:
• To the neck
• To the jaw
• Down the arm
• Not positional

13. Additional complaints:
•Dyspnea
•Palpitations
•Nausea
•Diaphoresis
•Epigastric pain

14. Physical examination:
•atients with unstable angina may have any (or none)
of these findings:
•↑ BP
•↑ HR
•S3 or S4 heart sounds
•New mitral regurgitation murmur
•Change in intensity of existing murmurs
Management:
Mona therapy-Morphine, oxygen therapy, Nitrates,
Aspirin

15. References:
• Chaudhary, I. (2020). Microvascular angina: angina
pectoris with normal coronary arteries. UpToDate.
Retrieved May 24, 2021,
from https://www.uptodate.com/contents/microvascular-
angina-angina-pectoris-with-normal-coronary-arteries.
• Mahler, S.A. (2021). Angina pectoris: chest pain caused
by fixed epicardial coronary artery obstruction. UpToDate.
Retrieved May 24, 2021,
from https://www.uptodate.com/contents/angina-pectoris-
chest-pain-caused-by-fixed-epicardial-coronary-artery-
obstruction.

16. •Simons, M., Alpert, J.S. (2020). Acute coronary
syndrome: terminology and classification. UpToDate.
Retrieved May 24, 2021,
from https://www.uptodate.com/contents/acute-
coronary-syndrome-terminology-and-classification
•Goyal, A., Zeitser, R. (2021). Unstable angina.
StatPearls. Retrieved May 24, 2021,
from https://www.ncbi.nlm.nih.gov/books/NBK44200
0/