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TH
Name:
Khairul Fariza Binti Khairudin
A122581
PATIENTS INFORMATION
Name: NCK
R/N: N256391
Date of admission: 29/04/2012
Age: 77
BW: 60 kg
Ht: 155 cm
MEDICAL HISTORIES
C/C: Presented with left sided chest pain
preceded with palpitation
FH:
Nil
PAST MEDICATION
HISTORY
1. T. Vastarel MR 35mg BD
Gender: Female
Race: Chinese
BMI: 25
PAST SURGICAL
HISTORY
Coronary Angiogram
(COROS) in 2009
Description of reaction
-
PCIs
-
30/4
124/56
1/5
107/53
2/5
122/55
HR (b/min)
64
56
53
60
RR (c/min)
22
24
24
o
Temp ( C)
37.2
37.4
36.4
Impression: The heart rate of this patient is slightly lower might be caused by the
Bisoprolol.
Endocrine
FBS
5.2
HbA1c (<6.5%)
5.6
Impression: The blood glucose level of this patient is normal.
FBC
WBC (4-11x109/L)
6.3
5.6
RBC (3.8-4.8x1012/L)
Hb (12.3-15.3 g/dL)
12.6
13.0
Hct (37-47%)
37.8
Platelet (150-400x109/L)
195
188
MCH (28-33 pg)
31.4
MCHC (15-45 g/dL)
33.5
MCV (76-95 fL)
Neutrofil (40-75%)
52
Lymphocyes(20-45%)
38.7
Monocytes(2-10%)
5.3
Eosinophil (1-4%)
3.5
Basophil (0-1%)
0.5
Impression: The full blood count results showed normal readings, indicating no
presence of infection.
LFT
ALT (0-31 u/L)
16
14
ALP (35-104 u/L)
60
59
T. Bili (0-17 umol/L)
7
14
Albumin (35-50 g/L)
40
42
T. Protein (66-87 g/L)
69
71
Impression: The liver enzymes level of this patient is normal, indicating normal liver
function.
RP & BUSE
SrCr (62-100 umol/L)
CLCr (mL/min)
Na+ (135-150 mmol/L)
K+ (3.5-5.0 mmol/L)
Urea (2.5-6.4 mmol/L)
Mg
82
67
84
62
137
3.3
8.6
0.67
139
3.8
6.1
137
4.0
9.8
139
3.7
9.2
0.75
No
.
Medication Name
Regimen
Date start
Indication
0.25mg in 100cc
over 30 minutes
(stat dose)
2/5
Treatment of atrial
fibrillation
1.25mg OD
2/5
Treatment of
hypertension
75mg OD
1/5
Reduces rate of
atherothrombotic events
in patients with unstable
angina
150mg OD
30/4
Anticoagulant agent
2.5mg OD
30/4
Prevention of
complications of
unstable angina
Fondaparinux sodium
2.5mg/0.5ml prefilled syringe
(Arixtra)
40mg ON
29/4
Treatment of
dyslipidemia
20mg OD
30/4
10mg TDS
30/4
1 tab OD
30/4
Treatment of
hypertension
0.5mg PRN
2/5
Prophylaxis and
treatment of angina
10
Perindopril 4mg +
Indapamide 1.25mg tab
(Coversyl Plus)
Glyceryl trinitrate 0.5mg tab
(GTN)
Warfarin sodium 2mg tab
11
12
2mg OD
Trimetazidine MR 35mg tab
(Vastarel MR)
Anticoagulant agent
35mg BD
30/4
Prophylactic treatment of
episodes of angina
pectoris
Route
29/4
30/4
Date
1/5
IV
Oral
/
/
(stat)
/
Oral
Oral
IV
/
(stat)
2/5
/
3/5
6
7
8
9
10
11
12
SUMMARY OF PROGRESS
Date
Subjective
29/4 Underlying HPT,
dyslipidemia, mild to
moderate nonobstructive CAD, no
collapsing pulse, apex
beat non displaced, no
pedal edema.
30/4
Underlying HPT,
dyslipidemia, mild to
moderate nonobstructive CAD, no
collapsing pulse, apex
beat non displaced, no
pedal edema.
Oral
Oral
/
/
/
/
Oral
Oral
S/L
Oral
Oral
Objective
BP : 89/61
PR : 68
INR : 2.14
Assessment
Unstable angina
ECG shows
bradycardia,
ventricular
ectopic
Plan
-Start Fondaparinux
2.5mg
-cont. T. Vastarel
MR 35mg bd
-cont. S/L GTN prn
-cont. T. Bisoprolol
7.5mg od
-cont. T. Perindopril
4mg +Indapamide
1.25 mg
-cont. T. Isosorbite
Dinitrate 10mg tds
-cont. T. Omeprazole
20mg od
-cont. T. Lovastatin
40mg on
-T. Warfarin 2mg od
- ECG start if chest
pain.
BP : 100/57
PR : 54
T : 37
RR:20
Unstable angina
-Cont. Fondaparinux
and other medication
-withold Bisoprolol
-ECG start if chest
pain
-refer cardio for
angiogram
1/5
2/5
BP: 146/86
PR : 109
T : afribile
ECG- AF no
obstructive
changes, unstable
angina, fast AF
but
hemodynamicall
y stable
BP :138/74
PR : 70
INR : 2.15
AF, unstable
angina,
MAJOR DIAGNOSIS
a. Pathophysiology/Pathogenesis of issue
Unstable angina is characterised by an imbalance between myocardial oxygen supply and
demand. The most common cause of UA is reduced myocardial perfusion that results from
coronary artery narrowing caused by a thrombus that developed on a disrupted
atherosclerotic plaque and is usually nonocclusive. Microembolisation of platelet aggregates
and components of the disrupted plaque causing distal microinfarction is believed to be
responsible for the release of myocardial markers in many of these patients.
A less common cause is dynamic obstruction, which may be caused by intense focal
spasm of a segment of an epicardial coronary artery (Prinzmetals angina). This spasm is
caused by hypercontractility of vascular smooth muscle and/or by endothelial dysfunction.
Dynamic coronary obstruction can also be caused by the abnormal constriction of smaller
vessels.
A third cause of UA is severe narrowing without spasm or thrombus. This occurs in some
patients with progressive atherosclerosis or with restenosis after a percutaneous coronary
intervention (PCI).
The fourth cause is arterial inflammation, caused by or related to infection, which may be
responsible for arterial narrowing, plaque destabilisation, rupture and thrombogenesis.
Activated macrophages and T-lymphocytes located at the shoulder of a plaque increase the
expression of enzymes such as metalloproteinases that may cause thinning and disruption of
the plaque, which in turn may lead to UA .
b. Treatment goal
1. To immediate relief of chest pain due to angina attack ; this because sometimes the
patient chest pain do not resolve after taking single dose of S/L GTN and need extra dose
to resolve.
2. To prevent the recurrence of angina attack; the patient has AF and may cause heart failure
and MI.
3. Prevention of stroke and tachycardia-induced cardiomyopathy and amelioration of
symptoms; this because the patient have AF and may cause stroke and other symptoms
that present in the patient such as palpitation, chest discomfort, and shortness of breath.
c. Actual and recommended treatment
According to Clinical Practice Guidelines on UA/NSTEMI 2011, the goal of
management are to immediate relief of ongoing ischemia and angina, prevention of recurrent
ischemia, angina and serious adverse cardiac event. The first recommended medication is
oral antiplatelet agent such as acetylsalicyclic acid which is aldready given in this patient.
Next is Adenosine Diphosphate Receptor Agonist such as clopidogrel and ticlodipine. In this
patient clopidrogrel 75mg od is given and is appropriate. Anticoagulant also is recommended
in the guideline and in this patient, fondaparinux 2.5mg is given and is appropriate. Next
recommendation is anti-ischemic drug therepy which include nitrates and beta blocker. In
this patient, S/L GTN and isosorbide dinitrate is given while bisoprolol was withold in this
patient due to low heart rate that may be due to effect of bisoprolol. Since this patient not
suitable for taking beta blocker, calcium channel blocker such as verapamil or diltiazam can
be given as an alternative. Next is lipid modifying drugs is recommended as it have been
found to reduce major cardiac events such as atorvastatin and simvastatin, while this patient
had receive lovastatin. Lastly the recommended medication is ACE inhibitor for long term
prevention of recurrent ischemia and this patient has received perindopril.
Indications
Monitor CBC,
platelet count, stool
occult blood test, sign
and symptoms of
neurological
impairment
Antithrombolytic
agent. Act by
inhibiting adenosine
diphosphate pathway
of platelet thus
reduce platelet
aggregation.
Monitor efficacy
Controlled of blood
pressure to desired
target (130/80mmHg)
Acetylsalicylic acid
soluble 150mg od
Antithrombolytic
agent. Act by inhibit
synthesis of
thromboxane A2 thus
interfere platelet
aggregation.
Measure salicylate
concentration for
therapeutic effect is
about 30mg/dL.
Isosorbide dinitrate
10mg tds
Prevention of angina.
Nitrates is taken up
by vascular smooth
muscle, metabolized
to nitric oxide,
stimulate guanylate
cyclase, convert GTP
to cGMP, increase
cGMP activate
protein kinase G,
dephosphorylase
Tablet clopidogrel
75mg od
Monitor safety
Reduction in
frequency of angina
attack.
Prothombine time
Ex vivo test of
platelet aggregation,
electrocardiogram,
CT/MR scan to
diagnosis of stroke.
Lovastatin 40mg
On
GTN 0.5mg
Acute treatment of
angina. Nitrates is
taken up by vascular
smooth muscle,
metabolized to nitric
oxide, stimulate
guanylate cyclase,
convert GTP to
cGMP, increase
cGMP activate
protein kinase G,
dephosphorylase
mouth or blurred
vision developed.
Lipid profile
monitoring with
target LDL achieved.
Obtain lipid profile
for response at 4
weeks.
Monitor liver
function test before
initiating therapy, at 6
and 12 weeks after
initiation of therapy
or elevation of dose,
and 6 months
thereafter in patient
with history of
hepatic impairment of
patient clinically
indicated. Assess
creatinine kinase
levels when
symptomatic
myopathy occurs.
May consider
monitoring creatinine
kinase levels to
patient initiating
lovastatin therapy or
when dose increased.
Temporary
discontinue treatment
if myopathy
suspected or serum
transminase levels
exceed 3 times
normal level.
Monitor for side
effect of GTN:
headache, postural
hypotension, reflex
tarchycardia.
However the side
effect is lesser
because beta blocker
is given.
T. Trimetazidine MR
(Vasteral MR) 35mg
b.d.
T. Bisoprolol
Fumarate7.5mg od
Perindopril Erbumine
4mg and Indapamide
1.25mg
Digoxin
Treatment of atrial
fibrillation
Blood pressure
Description of
issue
Pain
management
Complication of issue
Management of issue
Monitoring of issue
Drug
interaction
(Potential)
Stop Fondaparinux
after the completion
of regimen
Drug
The sublingual GTN
administration may not be
technique
administered correctly
because the angina
attack is not resolved
after 3 tablets
REFERENCES
1. MIMS Malaysia
2. Lacy, C.F., Armstrong, L.L. et al. 2010-2011. Lexi-Comps Drug Information Handbook.
3.
4.
5.
6.
7.
8.
19th Edition.
WHO Pain Management Ladder
Clinical Practice Guidelines on the Management of UA and NSTEMI, June 2011.
Clinical Practice Guidelines on the Management of Hypertension, February 2008.
Clinical Practice Guidelines on the Management of Dyslipidemia
Braunwald, E. 1989. Unstable angina: A classification. Circulation 80: 410-414.
Prisant, L.M., von Dohlen, T., Rogers, W., Houghton, J.L., Carr, J.L. & Frank, M.J. 1992.
Pharmacotherapy of unstable angina. Journal of Clinical Pharmacy 32: 390-399.
9. Patterson, D.L. 1988. Management in unstable angina. Postgraduate Medical Journal 64:
271-277.