Unstable Angina Pectoris

UNSTABLE ANGINA PECTORIS (UAP)

Supervisor:

dr. Muzakkir Amir, SP.JP, FIHA. FICA.

CARDIOLOGY DEPARTMENTMEDICAL FACULTY

MAKASSAR2013

Presented by:

Faradhillah A Suryadi C11108340

CASE REPORT CARDIOLOGY DEPARTMENT

PATIENT’S IDENTITY Name : Mr. I Gender : Male Umur : 64 y.o Reg. Number : 595424 Admitted Date : 25th, April 2013

UAP - CASE REPORT CARDIOLOGY DEPARTMENT

HISTORY TAKING

Chief Complaint : Chest pain Structural anamnesisIt 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 (-)


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


PHYSICAL EXAMINATION General Appearance :

Moderate-illness /Malnutrition/composmentis Vital Sign :

BP : 150/100 mmHg Pulse : 108 x/minute, regular RR : 28 x/minute ; Temp: 36,7º 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 : 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 (-)


Abdominal Examination : Inspection : Convex, following breath

movement Palpation : Liver and spleen

unpalpable Percussion : Tympani Auscultation: Peristaltic sound (+), normal

Extremities : Oedema (-)


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

ECG (25/4/2013)

ECG 25/4/13

ECG INTERPRETATIONRhythm : Sinus RhythmQRS Rate : 89 bpmPR interval : 0.12 secAxis : normoaxis P Wave : 0,12 secQRS complex : 0,08 secST segment : normalConclusion : Sinus rhytm, HR 89x/ minute

normoaxis, poor R wave progression-


LABORATORY FINDINGS Complete Blood CountWBC : 9,48x103 uLHB: 13,2 g/dlHCT : 38,9%PLT : 290x103 uL

ElectrolyteNatrium : 145Kalium : 3,44Chloride : 105

EnzymesCK : 43 u/LCK-MB : 10,5 u/LTroponin T : negatif

Blood chemistrySGOT : 18SGPT : 16Ureum : 31Creatinin : 0,5Uric acid : 7,3Glucose :120 mg/dl

Lipid ProfileTrigliserida : 209LDL : 154HDL : 30Total Cholesterol : 204


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

ECHOCARDIOGRAM

WORKING DIAGNOSISUNSTABLE ANGINA

PECTORIS&

HYPERTENSION GR.I


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 0-1-0Clopidogrel (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


PLANNING ECG / day


DISCUSSION

UAP


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.


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


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, ad-hesion, and aggregation of platelets and the activation of the clotting cascade, resulting in the formation of an occlusivethrombus. If this process leads to complete occlusion of the artery, then acute myocardial infarction with ST-segmentelevation occurs. Alternatively, if the process leads to severe stenosis but the artery nonetheless remains patent, thenunstable angina occurs.


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

CAUSES


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


UAPIf 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


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


CharacteristicClass/

CategoryDetails

Severity I Symptoms with exertion

II Subacute symptoms at rest (2-30 d prior)

III Acute symptoms at rest (within prior 48 h)

Clinical precipitating factor A Secondary

B Primary

C Postinfarction

Therapy during symptoms 1 No treatment

2 Usual angina therapy

3 Maximal therapy

BRAUNWALD CLASSIFICATION

Tan, A Walter. Unsta ble Angina Pectoris Clinical Presentation (updated 7th Dec 2011) http://emedicine.medscape.com/article/159383-overview#showall


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


ACS RISK ASSESMENT

CORONARY ARTERY DISEASE

CAD

ACS

UAP

NSTEMI

STEMIStable Angina Pectoris


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.


DIAGNOSIS

Oxford Handbook of Clinical Medicine 6th Edition

WHO Diagnostic Criteria

Clinical history of ischemic type chest

pain lasting for more than 20

minutes

Changes in serial ECG tracings

Rise and fall of serum cardiac

biomarkers such as creatine kinase-MB

fraction and troponin

http://en.wikipedia.org/wiki/Creatine_kinase



http://en.wikipedia.org/wiki/Troponin

No

Yes

Yes

No

ST-elevation Myocardial Infarction

NSTEMI( Non ST-Elevation

Myocardial Infarction )

Unstable Angina

Signs of myocardial ischemia

↑ Biochemical cardiac markers ?

ECG

Lab

ST segment elevation?

DIAGNOSIS

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 ECGThe 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

PROGNOSIS


RISK FACTORS

Modifiable: Hypertension Diabetes

Mellitus Dyslipidemia Smoking Obesity

Non-modifiable: Gender: male Age >45 years old Personal history of

Coronary Artery Disease

Family history of Coronary Artery Disease


34

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).


Yeghazartan, Y., Braunstein, J., Stone, P. Unstable Angina Pectoris (review article) NEJM Vol.342(2):101-114. January, 2000. Massachusets Medical Society

Patient CharacteristicsRecurrent angina/ischemia at rest or with low-level activities despite intensive medical therapyElevated cardiac biomarkers (TnT or TnI)

New or presumably new ST-segment depression

Signs or symptoms of heart failure or new or worsening mitral regurgitationHigh-risk findings on noninvasive stress testing

High-risk score (eg, TIMI, GRACE)Reduced LV systolic function (LVEF less than 40%)

Hemodynamic instability

Sustained ventricular tachycardiaPCI within 6 months

Previous CABG

Conservative Low-risk score (eg, TIMI, GRACE)

Patient or physician preference in the absence of high-risk features

MANAGEMENT

http://www.cardiosmart.org/HeartDisease


THANK YOU dr. Muzakkir Amir, Sp.JP, FIHA, FICA


Unstable Angina Pectoris

Health & Medicine

Transcript of Unstable Angina Pectoris