STABLE ANGINA

PECTORIS

By : Fawza Nabila Faudzi

Supervisor : dr. Pendrik Tandean, SpPD-KKV. FINASIM

PATIENTS IDENTITY
NAME
: Mr. T
BIRTH DATE
: 09-03-1966 (48
years)
ADDRESS : Attang Salo Kab
Pangkep
MEDICAL RECORD : 426285
DATE OF ADMISSION : 17th
December 2014

HISTORY TAKING
Chief Complaint : Chest pain
Present Ilness History :
He has been suffering from increasing
chest discomfort for the past 1 year.
About 6 months ago, he noted that the
chest pain episodes had become more
frequent. Described as chest pain
radiating to the left arm, duration of
pain : less than 5 minutes, pain is
precipitated by stress or physical
activities, but always resolved with rest.
No shortness of breath and no nausea.

HISTORY TAKING
Past Ilness History :
Neuropathy was diagnosed during a
clinic visit 3 months ago; he takes
carbamazepin 3 times per day and
sohobion 1 tablet daily.
Social Life:
Smoked 1 pack of cigarretes per day for
the past 10 years.
Drink beer occasionally

RISK FACTOR
Non Modifiable :
Gender : Male
Age > 45 years

Modifiable :
Obesity (169cm height; 80cm weight)
Smoking
Alcohol

PHYSICAL EXAMINATION
General Status
Moderate illness/ Overweight/ Compos Mentis
Weight : 80 kg
Height : 169 cm
BMI : 28,5 kg/m2

Vital Status
Blood pressure
Heart rate

: 130/80 mmHg
:76 bpm

Respiratory rate : 20 bpm

Temperature

: 36,5 oC

HEAD AND NECK

No anemic, no icteric
No cyanosis
JVP R+2cmH20

LUNG

Inspection : Symmetry left=right

Palpation
: Mass (-), no tenderness
Percussion : Sonor
Auscultation
: Vesicular
Rhonchi -/-,
wheezing -/-

HEART
Inspection
: Ictus cordis not visible
Palpation : Ictus cordis not palpable, thrill (-)
Percussion
:
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea axillaris anterior sinistra
Auscultation : Heart sound I/II regular, murmur (-)

ABDOMEN
Inspection :
Auscultation :
Palpation
:
Percussion :
EXTREMITIES
No edema

flat, follows breath movement

peristaltic (+), normal
liver and spleen not palpable
Tympani

ELECTROCARDIOGRAM

Sinus rhythm
Heart rate
: 64bpm
Axis
: Left Axis Deviation
P Wave
: 0.10 s
PR interval
: 0.20 s
QRS Complex : Duration : 0,12 s
Configuration : Q pathologic at V1,
V2,
V3, V4, V5
ST segment
: ST elevation at V1, V2, V3, V4, V5
Conclusion :
Sinus rhythm, HR 64 bpm, left axis deviation,
STEMI Whole Anterior

RADIOLOGY (CXR)
-Cardiomegaly
with dilatation,
elongation et
atherosclerosis
aortae
-Right
diaphragm
elevation

LABORATORY FINDINGS
Hemoglobin

13.4 gr/dl

Leucocyte

12.0 x 103/uL

Thrombocyte

390 x 103/uL

Plasma glucose

147 mg/dl

Electrolyte

Sodium (Na) : 143

mmol/l
Potassium (K) : 3.6
mmol/l
Chloride (Cl) : 104
mmol/l

CK

34.00 U/L

CK-MB

11.5 U/L

Troponin T

<0.02

Ureum

23 mg/dl

Creatinine

1.1 mg/dl

SGOT

24 U/L

DIAGNOSIS
Stable Angina Pectoris CCS II

MANAGEMENT

Aspilets 80mg/24 hours/oral

Clopidogrel 75 mg/24 hours/oral
Nitrokaf Retard 2.5 mg/12 hours/oral
Atorvastatin 20 mg/24 hours/oral
Captopril 12.5 mg/8 hours/oral
Omeprazole 40mg/24 hours/intravenous
Laxadine syrup 15ml/24 hours/oral
Alprazolam 0.5mg/24 hours oral
Micardis 80mg/24 hours/oral

DISCUSSION

Definition
Stable angina: clinical syndrome
characterized by discomfort in chest,
jaw, shoulder, back or arms
Elicited by exertion or emotional stress
Relieved by rest or nitroglycerin

Terms is usually confined to cases in

which the syndrome can be
attributed to myocardial ischaemia

Epidemiology
The prevalence of angina increases
sharply with age in both sexes from 0.1
1% in women aged 4554 to 1015% in
women aged 6574 and from 25% in men
aged 4554 to 1020% in men aged 65
74.
Therefore, it can be estimated that in
most European countries, 20 00040 000
individuals of the population per million
suffer from angina.

Pathophysiology of
Angina

Symptoms of Stable Angina

Pectoris
The pain or discomfort:
Occurs when the heart must work harder,
usually during physical exertion
Doesn't come as a surprise, and episodes of
pain tend to be alike
Usually lasts a short time (5 minutes or less)
Is relieved by rest or medicine
May feel like gas or indigestion
May feel like chest pain that spreads to the
arms, back, or other areas

Algorithm for the initial

evaluation of patients with
clinical symptoms of angina (1)

Algorithm for the initial

evaluation of patients with
clinical symptoms of angina (2)

Classification of Angina

Anti Anginal Drugs

Aims of treatment
To improve prognosis by preventing
myocardial infarction and death

Reduce plague progression

Stabilize plaque
Prevent thrombosis if endothelial
dysfunction or plaque rupture occur

To mininize or abolish symptoms

Pharmalogical agents to reduce

symptoms and ischemia

Nitrates
Short acting nitrates
Rapidly acting formulations of nitroglycerin provide effective
symptom relief in connection with attacks of angina pectoris,
and may be used for situational prophylaxis.
The pain relieving and anti-ischaemic effects are related to
venodilatation and reduced diastolic filling of the heart (reduced
intracardiac pressure), which promotes subendocardial
perfusion.

Long acting nitrates

Treatment with long-acting nitrates reduces the frequency and
severity of anginal attacks, and may increase exercise tolerance.
Studies of long acting nitrate treatment after myocardial
infarction have failed to show prognostic benefit.
Due to nitrate tolerance, patients treated with long acting
nitrates should have a nitrate free interval each day to
preserve the therapeutic effects.

Antithrombotic drugs
Antiplatelet therapy to prevent
coronary thrombosis is indicated, due
to a favourable ratio between benefit
and risk in patients with stable CAD.
Low-dose aspirin is the drug of choice
in most cases, and clopidogrel may
be considered for some patients.

 Low-dose aspirin
Aspirin remains the cornerstone of pharmacological prevention
of arterial thrombosis.
It acts via irreversible inhibition of platelet COX-1 and thus
thromboxane production, which is normally complete with
chronic dosing 75 mg/day.

Clopidogrel
Compared with aspirin 325 mg/day, clopidogrel 75 mg/day was
slightly more effective (ARR 0.51% per year; P 0.043) in
preventing cardiovascular complications in high risk patients.
Gastrointestinal haemorrhage was only slightly less common
with clopidogrel when compared with aspirin treatment
Clopidogrel is much more expensive than aspirin, but may be
considered in aspirin intolerant patients with significant risks of
arterial thrombosis.

B- Blocker
Beta-1 blockade by metoprolol or
bisoprolol have been shown to
effectively reduce cardiac events in
patients with congestive heart failure.
A nonselective beta-blocker also
blocks alpha-1 receptors, also reduces
risk of death and hospitalisations for
cardiovascular causes in patients with
heart failure

Algorithm of treatment