Clinical Lecture Demonstration Unstable Angina Tharuka Harischandra Nadeesha Jayakody

1. Clinical lecture demonstration
Tharuka Harischandra
Nadeesha Jayakody
Group J
UNSTABLE
ANGINA

2. Mrs. K.V.P
53 Years old
Dehiwala
Presented to the ward with Chest Pain
Introduction

3. She is a known β Thalassemia trait patient who
has been investigated for exertional angina in
2019 and poor clinic follow up.

4. History of presenting complain
• A patient who has been investigated for exertional angina in 2019,with
defaulted follow up and poor drug compliance presented with sudden
onset of tightening type retrosternal chest pain lasted about 30 minutes.
• Pain occur at rest, when she was lying on bed
• Radiated to neck and left arm
• Associated with autonomic symptoms
Sweating
Nausea
Palpitation
No Vomiting
No fecal or urinary incontinence

5. • Severity - Pain score 6/10
• Pain is relieved by 1 tab of sublingual GTN
• History of worsening of exertional angina for last one
month duration
• No exertional dyspnea
• History of intermittent claudication with 200m
claudication distance for last 3 months (not investigated)
History of presenting complain cont.

6. • Acute coronary syndrome
• Aortic dissection
• Pulmonary embolism
• GORD
• Pneumonia
• Trauma to chest
• Costochondritis
Differential diagnosis

7. Excluding Differential diagnosis
• No severe tearing type chest pain
• No radiation to tip of scapula
• No haemoptysis
• No DVT history
• No pleuritic type chest pain
• No fever or productive cough
• No burning type pain
• No dyspeptic symptoms
• No history of trauma
• No pain on touch
Aortic dissection
Pulmonary embolism
Pneumonia
GORD

8. Risk factors
• Past history of stable Angina
• First degree relative of ischemic heart disease at 48 years
of age
• Thalassemia Trait
• Sedentary life style
• Post menopausal but not on HRT
• No active or passive smoking
• No consumption of alcohol

9. Complications
• No symptoms of heart failure like
Paroxysmal nocturnal dyspnoea
Orthopnea
Exertional dyspnoea
History of lower limb swelling
• Reduced quality of life
(affected on the activities of daily living)

10. Past medical history
(1) Exertional angina (2019)
ECG
ST depression in V5, V6, II, III, aVR
High sensitivity Trop I
Negative
2D ECHO
EF 60%
Mild AR
Lipid Profile
Total cholesterol 169 mg/dl (<200)
HDL 47 mg/dl (>60)
LDL 106 mg/dl (60-130)
Triglicerides 75 mg/dl (<150)
eGFR 101 (>90)
SGPT 13.7 (<50)
Na 140 mEq/l (135-145)
K 3.6 mEq/l (3.5-4.5)
FBS 97 mg/dl
Hb 9.3 g/dl

11. (2) β Thalassemia trait
• No history of DM, HTN, DL
Blood picture
Hypochromic microcytic RBC
Target cells
Pencil cells
Comment - Thalassemia trait +/- iron deficiency
Suggestions –Serum ferritin, HPLC, Folate therapy

12. History of gynecological surgery 20 years ago
to investigate for subfertility
(No record available)
Past Surgical history

13. •Post menopausal
•Sub fertile
•Recurrent T1 miscarriages - 4
Gynecological history

14. Atorvastatin 40mg nocte
Atenolol 25mg nocte
Aspirin 75mg nocte
Sub lingual GTN 1 tab sos
Poor compliance of drugs for last 3 months
Drug history

15. No known allergies for food, drug or plasters
Allergy history

16. •Sister has had Ischemic Heart Disease at age
of 48 years
•Mother had diabetes mellitus and
hypertension
Family history

17. • Married
• Housewife
• Lives with husband
• No children
• Educated up to grade 8
• Good family support
• Poor insight of disease
• Poor monthly income
• Nearest hospital CSTH
Social history

18. Examination
Patient is well looking, and lying comfortably on bed
Height – 152 cm Weight- 68 kg BMI- 29.43 (Over weight)
Conscious and rational
Mildly pale but not icteric
No xanthelasma , corneal arcus
No cervical lympadenopathy
No finger clubbing
CRFT < 2 seconds
No peripheral cyanosis
No ankle oedema
General examination

19. Cardiovascular examination
Pulse rate- 72 bpm regular and in good volume, no collapsing pulse
All peripheral pulses present,
No radio-radial, radio-femoral delay
Blood pressure- 140/80 mmHg
No elevated JVP
No thoracic deformities or scar marks
No thrills or heaves
Apex felt at 5th intercostal space in mid clavicular line
S1 and S2 heard with no added sounds
Carotid bruit present

20. Respiratory rate 16 breaths per minutes
Not dyspnoic
Symmetrical chest movements
No tracheal deviation
Resonanant in percussion
Air entry is equal in both sides
Vesicular breathing
No added sound
Respiratory examination

21. Symmetrically moved with respiration
No scars
Not tender
No hepatospleenomegaly
No ballotable kidneys
No free fluid
No hepatic or renal bruits
Bowel sound present in normal intensity
Abdominal examination:

22. GCS score 15/15
Cranial nerves are normal
No cerebellar signs
Upper limb and lower findings are normal
All reflexes were present
No sensory loss
Central nervous system examination

23. Summary
53 years old known patient with thalassemic trait in a
background history of stable angina presented with sudden
onset of severe retrosternal chest pain radiate to left arm
and neck with autonomic symptoms for 30min at rest.
No history of DM, HTN, DLD. Not on HRT.
On examination, pulse rate was regular 72 bpm with good
volume and character.
Blood pressure was140/80 mmHg. Rest of the examination
was normal.

24. Problem list
Acute medical
Chronic medical
Sudden onset retrosternal tightening type chest pain radiate
to neck (ischaemic type)
Exertional angina
Thalassemia trait with history of moderate anaemia,
treated with FeSO4
Symptoms of peripheral vascular disease

25. Social
Poor insight about the disease
Problem list cont.

26.  Acute coronary syndrome
Clinical diagnosis

27. Initial management
Investigations
ECG
High sensitivity Troponin I
CBS
FBC
CRP
Rapid antigen -Test covid 19

28. Initial Investigations
 SPO2 96%
 ECG -No acute ischemic changes
T inversion in V1,aVR
High sensitivity troponin I - Negative
 FBC : To exclude infections and identify the anaemia status in the background
history of Thalassemia trait
Hypochromic microcytic anaemia
 CBS : 112 mg/dl
 CRP : In order to exclude underlying infection
<5mg/L
WBC
(10^9/L)
7.86
Hb (g/dL) 10.1
PLT
(10^9/L)
256

29. Management
Aspirin 300mg STAT
Clopidogrel 300mg STAT
Atorvastatin 40mg STAT
Sub lingual GTN 1tab
S/C Enoxaparin 60mg STAT

30.  AST : 22.4 U/L (<50)
 ALT : 15.2 U/L (<50)
 Total bilirubin : 24.76 umol/L (5.0-21.0) H
 Bilirubin- Direct : 6.23 umol/L (0.0-3.4) H
 Bilirubin- Indirect : 18.5 umol/L
 Urea : 1.2 mmol/L (2.8-7.2) L
 Creatinine : 54.2 umol/L (74-110) L
 Sodium : 135.6 mmol/L (136-146) L
 Potassium : 3.5 mmol/L (3.5-5.1)

31. Clinically ischaemic type chest pain
NO acute ischaemic changes in ECG
High sensitivity troponin I – Negative
UNSTABLE ANGINA

32. Aspirin - why ?
 Aspirin – NSAID – Inhibit platelet aggregation
Prevent thrombus formation mainly in arteries.

33. Clopidogrel – Why?
Inhibit P2Y12 receptors of platelets
Inhibit ADP dependent platelet aggregation

34. Atorvastatin
Lipid lowering drug
Stabilize the high risk plaques

35. Further ward management
Pharmacological management
Aspirin 75 mg Nocte
Atorvastatin 40mg Nocte
Bisoprolol 2.5mg Mane
Ranolazine 500mg bd
Nicorandil 10mg bd
Sub lingual GTN 1tab SOS
S/C Enoxaparin 60 mg bd

36. Referrals
Cardiology referral for 2D ECHO
EF 60%
Mitral valve – normal
Aortic valve – normal
left ventricle –Normal
Right atrium , right ventricle – normal

37.  Non pharmacological management
• Dietary advices were given
• Life style modification
• Patient has been educated on importance of drug
compliance and proper clinic follow up.

38. Need revascularization with coronary
angiography ?
TIMI score – Thrombolysis in myocardial
infarction
Score 0-2 Low risk
Score 3-4 Intermediate risk
Score 5-7 High risk
High risk & intermediate groups –
coronary angiogram.
Low risk group- medically managed
Kumar & Clark’s 8th edition

39.  Our patient – TIMI score -1
Low risk
MEDICALLY MANAGED

40.  Aspirin 75 mg Nocte
 Atorvastatin 40mg Nocte
 Bisoprolol 2.5mg Mane
 Ranolazine 500mg bd
 Nicorandil 10mg bd
 Sub lingual GTN 1tab SOS
Discharge plan
1.Drugs

41. Discharge plan cont.
2.Bilateral lower limb arterial duplex scan to investigate
for intermittent claudication
3.Dobutamine stress test at NHSL as patient is having
difficulty in walking due to fractured left leg
If positive cardiology referral for angiogram
4.Review at the clinic in one week time with FBS and lipid
profile

42. THANK YOU