case presentation on unstable angina in SOAP format. About the disease, etiology, pathophysiology, symptoms, treatments, drugs to be given in angina and lifestyle modifications are included.

1. CASE PRESENTATION ON
UNSTABLE ANGINA
PRESENTED BY:
M.SAI SRUTHI
II/VI PHARM-D
Y17PHD0819
DEPARTMENT OF PARMACY PRACTICE
NIRMALA COLLEGE OF PHARMACY

2. •A 58 years old male patient admitted in the hospital with chief
complaints of chest pain since 2 months radiating to left upper
limb.
•The patient had history of dyspnea on exertion class
II,palpitations and sweating.
•The patient had past history of CVA.
•The above case was presented in the format of SOAPANALYSIS.
CASE SUMMARY

3. SUBJECTIVE EVIDENCE:
Chief complaints: chest pain since 2 months radiating to left
upper limb.
History of present illness: dyspnea on exertion class 2,
palpitations, headache and sweating.
Past history:
CVA
Personal history:
•Normal appetite.
•Regular bowel and bladder habits.
•smoker.
SOAP ANALYSIS

4. • OBJECTIVE EVIDENCE:
 PHYSICAL EXAMINATION:
• PR:80b/minute
• Bp:130/80mmHg
• Wt:95kg
 SYSTEMIC EXAMINATION:
• CVS:S1S2+
• RS:VBS+
• CNS:NAD

5. SNO PARAMETERS OBSERVED
VALUES
NORMAL
VALUES
1. Hemoglobin 13.4g/dl 11 to16g/dl
2. RBS 77mg/dl 180mg/dl
3. platelets 3.08lac/microliter 1.5 to 4.5lac
4. S creatinine 0.9mg/dl 0.6to1.2mg/dl
5. TSH 5.26mIu/l 0.4 to 4.0 milli-
international units
per liter
COMPLETE BLOOD COUNT

6.  ECHO:
• Normal CV function.
• EF:60%
• TMT:+ve
• CAD LMCA TVD
 Coronary angiogram:
• CAD mild LMCA , triple vessel disease.
 ECG:
• Bradycardia.

7. ASSESSMENT
• Based on the subjective and objective evidence the patient is
suffering with unstable angina.
• DEFINITION:
• Unstable angina or sometimes referred to as acute coronary
syndrome causes unexpected chest pain, and usually occurs
while resting.
• The most common cause is reduced blood flow to the heart
muscle because the coronary arteries are narrowed by fatty
buildups (atherosclerosis) which can rupture causing injury to
the coronary blood vessel resulting in blood clotting which
blocks the flow of blood to the heart muscle.

8.  CAUSES:
• Coronary artery disease due to atherosclerosis is the most common cause of
unstable angina. Atherosclerosis is the buildup of fatty material, called plaque,
along the walls of the arteries. This causes arteries to become narrowed and
less flexible. The narrowing can reduce blood flow to the heart, causing chest
pain.
• People with unstable angina are at higher risk of having a heart attack.
• Rare causes of angina are:
• Abnormal function of tiny branch arteries without narrowing of larger arteries
(called microvascular dysfunction or Syndrome X)
• Coronary artery spasm

9. RISK FACTORS:

10. PATHOPHYSIOLOGY:

11. • chest pain that feels crushing, pressure-like, squeezing, or
sharp
• pain that radiates to your upper extremities (usually on the
left side) or back
• nausea
• anxiety
• sweating
• shortness of breath
• dizziness
• unexplained fatigue
SYMPTOMS:

13. STANDARD TREATMENT:
• stop blood clots
• manage high blood pressure
• manage high cholesterol
• manage and stop angina.
 Management
• Management is directed toward
• (1) reducing myocardial oxygen demands
• (2) improving myocardial oxygen supply
• (3) assessing the patient's risk of progression to MI or having a complication
related to treatment.

14.  The following medications are used in the management of unstable
angina:
• Antiplatelet agents (eg, aspirin, clopidogrel)
• Lipid-lowering statin agents (eg, simvastatin, atorvastatin, pitavastatin)
• Cardiovascular antiplatelet agents (eg, tirofiban, eptifibatide, and
abciximab)
• Beta blockers (eg, atenolol, metoprolol, and propranolol)
• Anticoagulants (eg, heparin )
• Thrombin inhibitors (eg, bivalirudin, lepirudin, desirudin, and argatroban)

15. • Nitrates (eg, nitroglycerin IV)
• Calcium channel blockers (diltiazem, verapamil, or nifedipine)
• Angiotensin-converting enzyme inhibitors (ACEIs) (eg, captopril, lisinopril,
enalapril, and ramipril)
 Surgical intervention in unstable angina may include the following:
• Cardiac catheterization
• Revascularization

16. DRUG CHART:
S
n
o
Drug
name
Dose ROA Freq Duration Indication Category MOA Side effects Monitoring
parameters
1. T
nitroconti
n(GTN)
2.6
mg
p/o BD D1 D2 To reduce
chest pain
vasodilator NO dilates
smooth muscle.
Headache,hypo
tension,dizzine
ss,abd pain.
Bp,HR.
2. Inj
heparin
5000
units
s/c TID D1 D2 Pevention of
clots.
anticoagul
ant,.
Inactivaes
thrombin and
prevents
conversion of
fibrinogen to
fibrin.
Chest pain
,shock,thrombo
sis vasospasm.
Hb
,hematocrit,ble
eding
igns,platelet
count.
3. T met
xl(metopr
olol)
25
mg
p/o OD D1 D2 To treat
angina
Beta
blocker
Selective
inhibitor of beta
adrenergic R
Hypotension,br
adycardia,dizzi
ness,fatigue,pr
uritis.
ECG,HR,bp

17. S
no
Drug
name
Dose ROA Freq Duration Indication Category MOA Side effects Monitoring
parameters
4. Neb duolin
Albuterol
ipratropiu
m
1.25m
g
500
mcg
p/n TID D2 To relieve
SOB.
Anticholin
ergic
agent(bri-
onchodilat
or)
Relax sm and
open
bronchial
passage.
Dizziness,blad
der pain,inc
HB.
FEV1,
PFT,Bp,HR.
5. Neb
budecort(b
udesonide)
0.5 mg p/n BD D2 To relieve
SOB.
Corticoste
roid.
Controls
protein
synthesis,
depressses
migration of
polymorphon
uclear
leucocytes.
Bronchospasm,
epistasis,phary
ngitis.
Candida
infection.
6. T
alprax(alpr
azolam)
0.5 mg p/o OD D1 To reduce
anxiety
benzodiaz
epine
Bind to BZD
R in post
sympatin
GABA
neuron
enhance
inhitory effect
of GABA.
Drowsiness,fati
gue,sedation,sk
in rash, wt
gain.
Resp and CV
status

18. S
no
Drug
name
Dose ROA Freq Duration Indication Category MOA Side effects Monitoring
parameters
7. T
ecosprin(as
pirin)
150
mg
p/o OD D1 D2 To reduce
blood clots
Antiplatele
t action
Inhibit cox 1
and 2
Cardiac
arrhtmias,edem
a,
hypotension,sk
in
rash,utricaria.
Lipid
panel,clottin
g
factors,proth
rombin time.
8. T atorvas
(atorvastati
n)
40
mg
p/o OD D1 D2 To reduce
cholesterol
levels in
blood
HMG Co A
reductase
enzyme.
Inhibit HMG
Co A
reductase
enzyme.
D
,Heamorrhagic
stroke.
Lipid
panel,CPK,h
epatictransa
minase.

19. DRUG INTERACTIONS:
MODERATE:
Metoprolol and ALPRAZolam :
• may have additive effects in lowering your blood pressure. You may
experience headache, dizziness, light headedness, fainting, and/or changes in pulse or
heart rate.
Management: Avoid driving or operating hazardous machinery.
Aspirin together with heparin:
• This can cause you to bleed more easily. You may need a dose adjustment in addition
to testing of your prothrombin time or International Normalized Ratio (INR).
Nitroglycerin and ALPRAZolam :
•may have additive effects in lowering your blood pressure.

20.  metoprolol together with albuterol:
• may reduce the benefits of both medications, since they have opposing effects in
the body. In addition, metoprolol can sometimes cause narrowing of the airways.
 heparin together with nitroglycerin:
• may decrease the effects of heparin. Call your doctor if signs of blood clots such as
chest pain, shortness of breath, sudden loss of vision, or pain, redness or swelling in an
extremity.

21. PATIENT COUNSELLING
 ABOUT DISEASE:
 Unstable angina or sometimes referred to as acute coronary syndrome causes
unexpected chest pain, and usually occurs while resting.
 ABOUT DRUGS:
 Grapefruit juice can increase the blood levels of atorvastatin.
 Grapefruit and grapefruit juice may interact with ALPRAZolam and lead to potentially
dangerous side effects.
 Food can enhance the levels of metoprolol in your body.

22. LIFESTYLE MODIFICATIONS
• eating a healthier diet.
• lowering your stress.
• exercising more.
• losing weight if you are overweight.
• quitting smoking if you currently smoke.
• Manage the conditions of high cholesterol,
hypertension,diabetes and other diseases.
• Get regular medical checkups.
• Stop drinking alcohol.