Generally, the clinical manifestation of unstable angina is chest pain, pain or pressure at the back, neck, jaw, shoulder or arm and also abdomen, sweating, dyspnea, nausea and vomiting, dizziness and fatigue. Based on patient’s record, Mr. Zainal Arifin had a history of abdominal discomfort on the day of admission, 24th October 2018. Besides that, the patient also complains of nausea and vomiting at the early of admission.
Based on the patient’s medical history, En. Zainal Arifin suffered from high blood pressure for quite a long period, which might lead to serious health problems. Blood pressure is determined by the amount of blood pumps through the heart and the amount of resistance to blood flow in the arteries. Hypertension happens when the more blood pumps by the heart and the narrower the arteries. Thus, uncontrolled hypertension increases the risks of serious heart diseases, including stroke and unstable angina.
Unstable Angina is a type of acute coronary syndrome. It is often indistinguishable from NSTEMI and treated with nitroglycerin and aspirin. It occurs when plaque disruption happens at the artery stenosis. The accumulation of lipid-rich macrophages and smooth muscle cells simultaneously forms, usually covered by a fibrous cap, named as coronary artherosclerosis at the artery stenosis sites resulting in a thromboembolytic blockage of the vessel. When cap rupture occurs, the plaque is exposed to platelets, stimulating the activation of the coagulant pathway and forming a thrombus, bulging and causing vasoconstriction to narrow the artery vessel. As a consequence, the artery becomes vasoconstricted, the blood flow is temporarily blocked resulting increase in blood pressure in order to meet the blood oxygen demand at the myocardial muscles. The heart will react by increasing the cardiac output through the escalation of the heart rate. This process will initiate the heart muscle to become ischemic, resulting in complete coronary blockage which is myocardial infarction or incomplete coronary blockage, the chest pain (unstable angina) to the patient, even at rest.
Other than that, diabetes mellitus type 2 suffered by the patient may be the cause of unstable angina as a result of high amount of sugar in the blood, hyperglycemia due to insulin resistance. Insulin resistance has been attributed to elevate the levels of free fatty acids and proinflammatory cytokines in plasma, leads to decrease in glucose transport to the muscle cells, increase in breakdown of fat and elevates the hepatic glucose production. This condition may cause damage to the inner layer of the arteries. As the consequences, the fatty plaque begins to build up at the arteries, forming the atherosclerosis. Over time, the plaque hardens and narrows the arteries causing blood accumulation at the plaque area and the reduction of oxygen-rich blood flows to the heart muscle. Sooner or later, the area of plaque may rupture due to the increase of force of the blood against the wall of blood vessels, and this condition augments the platelets to clump together with the plaque to form blood clots. The development of atherosclerosis limits the flow of oxygen-rich blood to the heart and may worsen the chest pain (angina).


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