Present by :

Alfiana Rahman C11115029

UNSTABLE ANGINA Supervisor :

Dr. dr. Idar Mappangara,
PECTORIS Sp.PD., Sp.JP(K)., FIHA.,
FICA., FAsCC
PATIENT IDENTITY
Name : Mr. PDS
Age : 65 y.o.
Address : Permata Sudiang Raya
MR : 872267
Date of Admission : February 4th 2019
HISTORY TAKING

Chief Complaint : Chest Pain

• It was felt since 3 days ago before admitted to the hospital. Chest
pain radiates to the left arm with cold sweat for more than 20
minutes. History of Cough(-), Wheezing (-), Rales (-) Fever (-),
Nausea (-), Vomit (-). Defecation is normal. Urination is normal.
PAST MEDICAL HISTORY
 History of chest pain (-)
 History of Hypertension (+), regulary not take medicine

 History of DM (-)

 History of Dyslipidemia (-)

 Family history with the same case (-)

PHYSICAL EXAMINATION

General status : Vital sign :

Moderate illness/ Compos Mentis BP : 146/90 mmHg
Pulse : 62 bpm, regular
Nutritional status :
RR : 20x/minutes
Weight : kg
Temperature : 36.5° C
Height : m NPRS : 1/ 10
BMI : kg/m2 ( )
 PHYSICAL EXAMINATION

Head and Neck examination  Lungs

: •
 Eye : Anemic Conjunctiva (-),
Icteric sclera (-)
 Lip : Cyanosis (-)
 Neck : JVP R +2 cm H2O
Palpation : Fremitus symmetrical left
together with right. Tenderness (-)
• Percussion : Limit liver-lung ICS VI
dextra; Right behind lung markings ICS
IX; Left behind lung markings ICS X.
• Auscultation : Breathing sounds :
vesicular. Additional sounds : minimal
Ronkhi in basal pulmonary. Wheezing (-/-).
 PHYSICAL EXAMINATION
Cor Abdomen
• Inspection : Ictus cordis does not • Inspection : Flat, follow the motion
seem of breath
• Palpation : Ictus cordis palpable, • Palpation : Liver and lien
thrill none impalpable
• Percussion : The upper limit ICS II Tumor mass (-), tenderness (-)
sinistra; Right border ICS IV linea • Percussion : Tympani (+)
parasternalis dextra; Left border ICS • Auscultation : Peristaltic (+)
V linea axillaris anterior normal impression
• Auscultation : BJ I/II pure reguler;
Heart murmurs (-).
 PHYSICAL EXAMINATION
 Extremity
• Warm extremity
• Pretibial edema none
• Dorsum pedis edema none
 LABORATORY FINDINGS
04/02/2019
Test Type Result Normal value
PT 9,8 seconds 10 – 14 seconds

Koagulasi INR 0.94 --

APTT 27,6 seconds 22.0 – 30.0 seconds

UREUM 24 mg/dl 10 – 50 mg/dl

Fungsi Ginjal
KREATININ 0.77 mg/dl L(<1.3);P(<1.1) mg/dl

SGOT 13 U/L <38 U/L

Fungsi Hati
SGPT 12 U/L <41 U/L

Imunoserologi Lain TROPONIN I <0.01 ng/ml <0.01 ng/ml

NATRIUM 139 mmol/l 136 – 145 mmol/l

Elektrolit KALIUM 3.9 mmol/l 3.5 – 5.1 mmol/l
KLORIDA 103 mmol/l 97 - 111 mmol/l
Blood chemistry GDS 102 140 mg/dl
ELECTROCARGIOGRAM (ECG)
(17/03/2018)

Sinus Rhythm
HR :
Regularity :r
Axis :
P Wave :
PR Interval :
QRS Complex :
ST Segment :
T Wave :
Conclusion :
 RADIOLOGY FINDING
(17/03/2018)

Conclusion :
 Echocardiography
(19/03/2018)
 Systolic function of left ventricle, Ejection
Fraction 53% (BIPLANE)
 Left Ventricle Hypertrophy Concentric

 Segmental hypokinetic

 Mild Left Ventricle Diastolic Dysfunction

 Coronary Angiography
(22/03/2018)
Cannulations of Left Coronary Artery and Right
Coronary Artery with Tiger 5F catheter found that
:
 Left main : Normal
 Left Anterior Descending : Proximal stenosis
70-75%
 Left Circumflex : Distal stenosis 80%
 Right Coronary Artery : Irregular
 PDA : Stenosis 80%
Conclusion :
 Coronary Artery Disease three vessel Disease
Suggestion : Revascularization
 Working Diagnose
UNSTABLE ANGINA PECTORIS (UAP)

Secondary Diagnosis :
Hypertension Heart Desiase
Management
 NaCl 0,9% (500 ml/24 hours/intravena)
 Oksigen 4 LPM via nasal canul
 Antiplatelet agent : Aspilet 160mg/24 hours/ oral (continue w/
Aspilet 80 mg/24 hours/oral)
 Antiplatelet agent : Clopidogrel 300mg/24 hours/oral
(continue w/ clopidogrel 75 mg/24 hours/oral)
 Anticoagulant : Fondaparinux (Arixtra 2,5 mg/24
hours/Subcutan)
 Bisoprolol : Concor 2,5 mg 24 hours/oral
 Nitrat : Nitral 500 mcg/8 hours/oral
 ACE-I : Captopril 12,5 mg/8 hours/oral
 Statin : Atorvastatin 40 mg/24 hours/oral
 ECG / DAY
PLANNING
 PCI
DISCUSSION
 Definition of
Unstable Angina Pectoris
 The form of ACS that results depends on the degree of coronary
obstruction and associated ischemia. A partially occlusive
thrombus is the typical cause of the closely related syndromes UAP
and NSTEMI with latter being distinguished from the former by
the presence of myocardial necrosis (Lily, 2011)
 Risk Factor
Modifiable Non-Modifiable
 Smoking  Age
 Diabetes Mellitus  Gender
 Dyslipidemia  Genetic
 Obesity
 Hypertension
 Physical inactivity
 Etiology of
Unstable Angina Pectoris
 Imbalance between O2 supply and demand
 Disruption of plaque and rupture

 Thrombosis

 Vasoconstriction
PATHOGENESIS
CLINICAL MANIFESTATION OF UNSTABLE
ANGINA PECTORIS

• A crescendo pattern in which patient with

chronic stable angina experiences a sudden
increase in the frequency, duration, and or
intensity of ischemic episodes
• Episodes of angina that occur at rest w/o
provocation
• New onset of anginal episodes describe as
severe, w/o previous symptomps of CAD
 ECG Changing
 No ST segment elevation
 ST segment depression ≥ 0,5 mm
in V1-V3 dan ≥ 1 mm in others
leads
 Symmetrical T inverted ≥ 2 mm
 DIAGNOSIS

ESC Guidelines for the management of acute coronary syndromes in patients presenting without
persistent ST-segment elevation. European Heart Journal (2011)
BRAUNWALD CLASSIFICATION
CANADIAN CARDIOVASCULAR SOCIETY FUNCTIONAL
CLASSIFICATION
 Treatment
Anti-ischemic therapies :
• β-blocker General measure :
•Nitrates •Pain control (morphine)
• +/- CCB •Supplemental O2 if needed
Antithrombotic therapies :
Antiplatelat agents :
•Aspirin
•Clopidogrel (or prasurgel)
Adjunctive thrapies :
Anticoagulants (use one) : • Statin
•LMWH (enoxaparin) •Angiotensin converting-
•Unfractionated intravenous enzyme inhibitor
heparin
•Fondaparinux
THANK YOU