UNSTABLE ANGINA PECTORIS

TIMI SCORE 4/7

By: Nur Sepdyanti (C11108342)

Supervisor: dr. Khalid Shaleh SpPD

PATIENT IDENTITY

Name : Mr. L.H.BAge : 71 years oldGender : MaleMedical record : 568120Date of admission : 13 th September

2012

HISTORY TAKING

• Chief complaint: Chest pain• Guided anamnesis:

Occured since 4 days ago, getting worse 1 day before admission. The patient complain of pain on the left side of chest, non radiated The pain felt like pin and needle feeling. Intermittent pain, frequency of recurrent attack > 5 times a day with increasing intensity, duration about 5-10 minutes. The pain doesnt triggered by activity and not relieved by resting. DOE (+) arises especially when chest pain relapse. Nausea (-), Vomiting (-),PND (-), orthopneu (-).

PAST ILLNESS HISTORY

- History of hypertension since 5 years ago, treatment irregularly.

- Smoking (+) since 30 years ago- Family history of heart disease (-)- History of dyslipidemia (unknown)- History of DM (unknown)

CLINICAL EXAMINATION

• GENERAL STATEModerate illness/normoweight/conscious

• VITAL SIGN- Blood pressure : 150/80 mmHg- Pulse : 80 bpm- Breathing : 22 x/minute- Temperature: 36.70C

Head Examination• Eyes: anemic -/-, icterus -/-• Lip : cyanosis (-)• Neck : lymphadenopathy (-), JVP R-2

cmH2OChest Examination• Inspection : symmetric R=L,

normochest• Palpation : mass (-), tenderness (-), VF

R=L• Percussion : sonor• Auscultation : breath sound :vesicular

additional sound : ronchi -/-wheezing -/-

Cardiac Examination• Inspection : IC wasn’t visible• Palpation : IC palpable • Percussion : normal heart size

• -Upper border : left 2nd ICS• -Lower border : left 5th ICS • -Right border : right parasternalis line• -Left border : left medioclavicular line

• Auscultation : Regular of I/II heart sound, murmur (-)

Abdominal Examination Inspection : flat and following breath

movement Auscultation : peristaltic sound

(+) ,normal Palpation : liver and spleen unpalpable Percussion : tympani, ascites (-)

Extremities - Oedema : pretibial -/-, dorsum pedis -/-

ELECTROCARDIOGRAM

Rhythm: sinus rhythmQRS rate: HR 69 bpmP wave : 0.06 secPR interval: 0.12 secQRS complex: 0.08 secAxis: Normo axisST segment: isoelectricT-wave inverted: I, AvL, V5, V6

Conclusion: sinus rhythm Hr= 69 bpm, lateral wall myocard ischemia

LABORATORY FINDINGTest Result Normal value

WBC7,23x103 mm3 4,0-10,0 x 103 mm3

RBC5,35 x 106 mm3 4,0-6,0 x 106 mm3

HGB14,5 g/dl 13,0-17,0 g/dl

HCT44,3 % 40,0-54,0 %

MCV82,8 fL 80-100 fL

MCH27,1 pg 27,0-32,0 pg

MCHC 32,7 g/dL 32-38 g/dL

PLT238 x 103 /uL 150-500 x 103

LABORATORY FINDINGTest Result Normal value

GDS110 110

Ureum20 10-50

Creatinin1,0 M(<1,3);F(<1,1)

SGOT19 <38

SGPT11 <41

Total Cholesterol156 200

HDL 26 M(>55);F(>65)

LDL75 <120

LABORATORY FINDINGTest Result Normal value

Trigliserida51 200

CK104 M(<

CK-MB13 <25

Troponin T- -

Uric Acid7,4 F(2,4-5,7), M(3,4-7,0)

WORKING DIAGNOSIS

• Unstable angina pectoris• HT Grade I on treatment

THERAPY• O2 2-4 liters/minute • IVFD NaCl 0,9 % 500cc/24hour• Farsorbid 5 mg/SL (when chest pain occured)• Farsorbid 10 mg 1-1-1• Antiplatelet:

– Aspilet 80 mg 1-0-0– Clopidogrel 75 mg 0-1-0

• Anti Hypertension:– Lisinopril 5 mg 0-0-1

• Simvastatin 20 mg 0-0-2• Alprazolam 0.5mg 0-0-1• Laxadyn Syrup 0-0-2• Arixtra 2.5 mg/day/SC

DISCUSSION

CAD

DEFINITIONAngina 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.

UNSTABLE ANGINA

• angina at rest (> 20 minutes)• new-onset (< 2 months) exertional

angina (at least CCSC III in severity)

• recent (< 2 months) acceleration of angina (increase in severity of at least one CCSC class to at least CCSC class III)

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

RISK FACTOR

Modifiable :- Smoking- Dyslipidemia - Raised Blood pressure- Diabetes melitus- Obesity

Modifiable :- Smoking- Dyslipidemia - Raised Blood pressure- Diabetes melitus- Obesity

Non-Modifiable :- Personal History of CVD- Family History of CVD- Age- Gender

Non-Modifiable :- Personal History of CVD- Family History of CVD- Age- Gender

DIAGNOSE

TIMI RISK FACTOR

MANAGEMENT

MANAGEMENT

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