1. CARDIOLOGY Decompensatio

8/18/2019 1. CARDIOLOGY Decompensatio

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CARDIOLOGY dr M Arman Nasution SpPD


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Congestive Heart Failure


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Gagal jantung (Heart

ailure!


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Classification


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Generally classified as the following:Left vs right failure

Systolic vs diastolic dysfunction

Backward vs forward failure

Low output vs high output cardiac failure

The degree of functional impairment

conferred by the abnormality (as in the!"# functional classification$


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ew !ork "eart #ssociation %unctional Classification

Class I: o limitation e&perienced inany activity and no symptoms fromordinary activities'

Class II : ild limitation of activity andcomfortable at rest or mild e&ertion

Class III : arked limitation of any

activity and comfortable only at rest

Class IV : #ny physical activity bringsdiscomfort and symptoms appear atrest


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Signs and symptoms


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Left Sided %ailure) Symptoms %orward %ailure: -oor systemic

circulation

+i..inessConfusionCool e&tremities at rest/asy fatigueability

/&ercise intolerance


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*ight Sided %ailure) Symptoms

Backward %ailure: Congestion of systemic capillaries

/&cess fluid accumulation in the body

-eripheral edema0 anasarca+ependent edema (foot1 ankle1 sacral$octuria#scitesLiver congestion (hepatomegaly1 2aundice and coagulopathy$

%orward %ailure: "ypotension


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Left Sided %ailure) Signs

on specific signs of respiratory distress:Tachypnea3ncreased work of breathing+ecreased vital capacity +evelopment of pulmonary edema:*ales0Crackles 4 initially at base1 throughout the lung

when severe

/&tremely severe pulmonary edema:Cyanosis (severe hypo&emia$


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Left Sided %ailure) SignsLaterally displaced ape& beat (heart enlargement$

S5 gallop rhythm (increased blood flow0 increasedintra cardiac pressure$

"eart murmurs) indicative of valvular diseases (Causeor result of heart failure$


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*ight Sided %ailure) Signs-eripheral pitting edema"epatomegaly6ugular venous pulse accentuated

by hepato2ugular reflu& (markerof fluid status$

-ositive abdomino2ugular test-arasternal heave (increased *7

pressure$#scites (late onset$


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#scites

-itting /dema of#nkle


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Cardiomegaly

-ulmonary /dema


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Biventricular %ailure-leural effusions) more common inbiventricular failures'

8nilateral failures cause right sidedeffusions (large area of right lung$

Signs:

+ullness of lung fields*educed breath sounds at lung bases


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,ther signs

Cardiomegaly

9eight loss

Tachycardia (;


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easuring elevated 67-

Common symptoms of

CC% (overview$


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"H# H#AR"Normal

Pat$olog%Heart ailure& L' R

Heart Disease Congenital& LR s$unts' RL s$unts' Ostru)ti*e

Is)$emi)& Angina' In+ar)tion' C$roni) Is)$emia' SuddenDeat$

H%pertensi*e& Le+t sided' Rig$t sided

,al*ular& AS' M,P' R$eumati)' In+e)ti*e' Non-In+e)ti*e'

Car)inoid' Arti.)ial ,al*es Cardiom%opat$%& Dilated' H%pertrop$i)' Restri)ti*e'

M%o)arditis' Ot$er

Peri)ardium& #/usions' Peri)arditis

"umors& Primar%' #/e)ts o+ Ot$er Primaries

"ransplants


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NORMAL eatures0111 L2da%

341-511 grams

617 o+ all deat$s (38 )an)er!

9all t$i):ness ; pressure(i


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"#RMSCARDIOM#GALY

DILA"A"ION' an% )$amer' or

allHYP#R"ROPHY' and )$amer'or all


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S


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Anterio


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Anterior

Lateral

Posterior

Septal

,AL,#S


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,AL,#SA,&"RICBSPID ?5 )m

MI"RAL ?? )mS#MILBNAR&PBLMONIC )m

AOR"IC 0 )m

CARDIAC AGING


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Sigmoid-s$aped *entri)ularseptum

De)reased le+t *entri)ular )a*it%

sie

In)reased le+t atrial)a*it% sie

C$amers

u):ling o+ mitral leaEets to=ard t$e

irous t$i):ening o+ leaEets

Mitral *al*e annular )al)i.) depositsAorti) *al*e )al)i.)

deposits

,al*es

At$eros)leroti) plaFue

Cal)i.) deposits

In)reased )ross-se)tional

luminal area

"ortuosit%

#pi)ardialCoronar%Arteries

Am%loid deposits

asop$ili) degeneration

(gl%)

Lipo+us)in depositionro=n atrop$%

In)reased suepi)ardial+at

In)reased mass

M%o)ardium

CARDIAC AGING

CARDIAC AGING


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CARDIAC AGING

At$eros)leroti) plaFue

#lasti) +ragmentation and )ollagena))umulation

Sinotuular jun)tion )al)i.) deposits

#longated (tortuous! t$ora)i) aorta

Dilated as)ending aorta =it$ rig$t=ard s$i+t

Aorta

RO9N


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RO9N A"ROPHY' H#AR"

LIPOBCSIN Pat$ologi) Pump


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g pPossiilitiesPrimar% m%o)ardial +ailure (MYOPA"HY!Ostru)tion to Eo= (,AL,#!

Regurgitant Eo= (,AL,#!

Condu)tion disorders (CONDBC"IONSYS"#M!

ailure to )ontain lood (9ALLIN"#GRI"Y!

CH


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CHD#INI"ION

"RIAD?! "ACHYCARDIA3! DYSPN#A

5! #D#MAAILBR# o+ ran: Starling me)$anismHBMORAL AC"ORS

Cate)$olamines (nor-epinep$rine!

ReninAngiotensionAldosteroneAtrial Natriureti) Pol%peptide (ANP!

HYP#R"ROPHY and DILA"A"ION

HYP#R"ROPHY


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HYP#R"ROPHY PR#SSBR# O,#RLOAD (CONC#N"RIC!,OLBM# O,#RLOAD (CH!

L,H' R,H' atrial' et)<

3 normal =eig$t is)$emia

5 normal =eig$t H"N

5 normal =eig$tMYOPA"HY' aorti)regurgitation


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& u ops%i di


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p %indingsCardiomegal%C$amer Dilatation

H%pertrop$% o+ m%o)ardial .ers'OCAR nu)lei


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+ id d il


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Le+t Sided ailure

Lo= output *s< )ongestionLungs

pulmonar% )ongestion and edema

$eart +ailure )ells

idne%spre-renal aotemia

salt and Euid retention

renin-aldosterone a)ti*ation natriureti) peptides

rain& Irritailit%' de)reasedattention' stupor)oma

Le+t Heart ailureS


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S%mptomsD%spnea

on e8ertion

at rest

Ort$opnearedistriution o+ perip$eral edema Euid

graded % numer o+ pillo=s needed

Paro8%smal No)turnal D%spnea (PND!

L#" Heart Failure


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L#" Heart FailureD%spnea

Ort$opnea

PND (Paro8%smal No)turnalD%spnea!

lood tinged sputum

C%anosis

#le*ated pulmonar%J9#DG#K pressure (PC9P!(nl > 3-?4 mm Hg!

ailure


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ailure#tiolog%

le+t $eart +ailure)or pulmonale

S%mptoms and signsLi*er and spleen

passi*e )ongestion (nutmeg li*er! )ongesti*e spleenomegal%

as)ites

idne%s

Pleura2Peri)ardium pleural and peri)ardial e/usions

transudates

Perip$eral tissues

Failure


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FailureA"IGB#

JDependentK edema

,D

Hepatomegal% ()ongestion!

ASCI"#S' PL#BRAL #BSION

GI

C%anosis

In)reased perip$eral *enous

pressure (C,P! (nl > 3-0 mmHg!

H#AR" DIS#AS#


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H#AR" DIS#AS#

CONG#NI"AL

(CHD!ISCH#MIC (IHD!HYP#R"#NSI,# (HHD!

,AL,BLAR (,HD!

MYOPA"HIC (MHD!


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"ricuspid atresia

1

120 "otal anomalous pulmonary venousconnection

1

136 "runcus arteriosus

4

388

"ransposition of great arteries

4

388 Aortic stenosis

4

396 Atrioventricular septal defect

5

492 oarctation of aorta5

5!! "etralog% o+ allot

!

!81 Patent du)tus arteriosus

8

836 Pulmonar% stenosis

101043Atrial septal de+e)t

424482

,entri)ular septal de+e)t

7In)iden)e per Million

Li*e irt$sMal+ormation

G#N#"ICS


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G#N#"ICSGene anormalities in onl% ?17 o+ CHD

"risomies 3?' ?5' ?4' ?' OMutations o+ genes =$i)$ en)ode +or

trans)ription +a)tors

"4

ASD',SD N3


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A"#$%&A'()A" '*'+,- "evie. of Anatomy / ysiology Assessment History and ysical Assessment

#iagnostics lanning

",&$, %F AA+%-* A#


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",&$, %F AA+%-* A#

H*'$%)%* Heart'tructures

7lood 'upply )A "A veins

onductive 'ystem 'inoatrial node A&node 7undle of His 7undle :rancur;in


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*#

*7

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L#

L7

S!ST/3CC3*C8L#T3,

S!ST/3CC3*C8L#T3,

)('

S!ST/3CC3*C8L#T3,


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%#(+$% A+HA*RA LA

R, L,

'A %#,

A& %#,

7(#), %F H$'

7(#),

7"AH

(">$?,

(">$?,

",&$, %F AA+%-* A#


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",&$, %F AA+%-* A#

H*'$%)%* Heartervous 'ystem ontrol

'*-A+H,+$

A"A'*-A+H,+$

",&$, %F AA+%-* A#


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",&$, %F AA+%-* A#

H*'$%)%* Heartroperties of te Heart

All or one rinciple"ytmicity,@cita:ility"efractorinessonductivityAutomaticity,@tensi:ility

",&$, %F AA+%-* A#


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",&$, %F AA+%-* A#

H*'$%)%* Heart'+"%>, &%)(-, '&B amount of :lood pumpedout .it eac contraction

H,A"+ "A+, H"B

A"#$A %(+(+ %B volume of :lood pumpedout per minute

C'& @ H"

",)%A#

AF+,")%A#


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",&$, %F AA+%-* A#


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",&$, %F AA+%-* A#

H*'$%)%* 7lood &essels

Arteries

-icrocirculation

&eins

Flo. "egulationressure gradient

Flo. resistance"ole of 7lood vessels

)ayers of te 7lood&essels

$ntima

-edia

Adventitia

",&$, %F AA+%-* A#


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",&$, %F AA+%-* A#

H*'$%)%*$"()A+$%'*'+,-$

()-%A"*

%"+A)

()-%A"* $"()A+$%


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*#

*7

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'*'+,-$ $"()A+$%


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S!ST/3CC3*C8L#T3,

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S!ST/3CC3*C8L#T3,


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H$'+%"* A# H*'$A) ,DA-ec; fordyspnea


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H$'+%"* A# H*'$A) ,DA-Heart $ Aaortic area

pulmonic area

tricuspid

mitral

Heart 'ounds'1 A& valve

closure

'2 semilunar vEclosure

'3 ventE allop'4 atrial gallop-urmursru:s


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H$'+%"* A# H*'$A) ,DA-7lood vessels$nspection

colorpallor ru:or cyanosis

circulation of e@tremitiesalpation

edema pulsesAuscultation

:ruit

#iagnostic Assessment


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#iagnostic Assessmenton$nvasive

,

#ynamic , 'tress +est

+readmill &ector

ardiogram

onocardiogram

,cocardiogram

est Dray

"adionuclide 'tudies

&enograpy

(+ #%),"

letysmograpy


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#iagnostic Assessment$nvasive

ardiac

ateteriGation

Arteriogram

Angiocardiogram

&enogram

)ympogram

7one -arro.

Aspiration'ternumiliac crestti:ia infantsB

#iagnostic Assessment


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#iagnostic Assessment7lood and (rine

'tudies7

Hematocrit

lotting time

+

++

A++,'"

lipid pro=le

serum enGymes'%+ '+ )#H>

&-A"enin +est

'cillings +est

H,-%#*A-$' -%$+%"$


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H,-%#*A-$' -%$+%"$

& nC 6 12 cm .ater-easures cardiac eIciency :ld volume

periperal resistance rigt ventricular pressure

0pt :e at mid a@illary line 5 cm :elo. testernum

dc ventilator .it reading C Juid overload C ypovolemia

H,-%#*A-$' -%$+%"$


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ulmonary Artery and ulmonaryedge ressure'.an anG cateter Joated at te rigt eartmeasures left side of te eart

$ntraarterial 7lood ressure "adial ArteryAllens +est

+,"-$%)%$,'


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+,"-$%)%$,'

&,+$)A+$% -%&,-,+ %F A$" $ / %(+ %F +H,)('

",'$"A+$% ,DHA, %F A',' ,D+,"A) /$+,"A)

,D+,"A) 7,+E A)&,%)$ / ()-%A"* A$))A"$,'

$+,"A) 7,+E '*'+,-$ A$))A"$,'

,"F('$% A&A$)A7$)$+* / -%&,-,+ %F A$))A"*7)%%# F%" ,DHA, %F A','


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lanning for Healt romotion

-odi=cation of Hig "is; Factors

romotion of irculation

revention of $nfection sypillis stap strep

german measlesenetic counselling

"ole of nutrition

Modi.)ation o+ Hig$ Ris:a)tors


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a)tors

dyslipedemia

ypertension

smo;ing

sedentarylifestyle

o:esity

stress

glucoseintolerance

alcool a:use

caKeine pollution

lanning for Healt -aintenance /


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lanning for Healt -aintenance /"estoration

7asic )ife 'upport Advanced )ife 'upport

lient it ardiac 'urgery losed Heart surgery %pen Heart 'urgery Heart +ranspant


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losed Heart surgery valvutomy

mitral commisurotomy

%pen Heart surgery


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A7B%-)$A+$%'

#*'"H*+H-$A'

+H"%-7%'$' A#()-%A"*,-7%)$'-

A"#$%,$ 'H%>

7),,#$

%(# $F,+$%

",A) FA$)(",

,),+"%)*+,$-7A)A,

%'+% '*H%'$'

H,A"+ +"A')A+


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H,A"+ +"A')A+"$+,"$A

1E ,nd 'tage of #isease

2E Freedom from ronic #isease

3E Family 'upport

4E Age L 50 yo

5E o psycological pro:lem

$-%"+A+

1E $mmunosuppressant / 'teroids 4 rs prior2E #onor"ecipient ompati:ility siGecrossmatcing

3E #onor Heart saline solution 4 up to 4 rs


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A"#$%&A'()A" #$'+("7A,'%"%A"* M $'H,-$ H,A"+ #$',A',

Arteriosclerotic Heart #isease

Angina ectoris

oronary $nsuIciency-yocardial $nfarction

%,'+$&, H,A"+ FA$)(",

H*,"+,'$%,"$H,"A) &A'()A" #$',A',

#$'%"#,"' %F +H, 7)%%#


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A$A ,+%"$'

1E '+A7),

2E ('+A7),

3E "$-,+A) coronary artery spasm

4E %+("A)

5E #,(7$+('


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$'H,-$A &' $FA"+$%$'H,-$A $FA"+$%

A$ '(7'+,"A)",''(",MH,A&$,''

'O(,,$

'(7'+,"A)

%'+"$+$&, P 'D%F 'H%>B

#("A+$% 35 -$ Q 5 -$

",$$+A+' '+",''M ,D,"+$% %

",'+

$+"%)*,"$,

",)$,&,# %+ ",)$,&,#

A"#$A +$''(,#A-A,

% ,"-A,+ ,"-A,+

A$A ,+%"$'


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A$A ,+%"$'#$A%'$'

itro +est 0E4mg

("'$ %A)'

1E %2 to myocardium

2E %2 demand

3E revent future episodes of angina


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%2 to -yocardiumAntiplatelets

alcium 7loc;ers

7eta :loc;ers

is;yM7randy

itrates

"A$#A+$ itroglycerine itrostat

Amylitrate

)%A+$$'#$'-

itroglycerineointment

+ransdermal

$&


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%2 #emand )imit activities 7"

-oderate ,@ercise

'edatives

armt


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revent Future ,pisodes#$,+ lo. calorie lo. saturated fat

o to:acco

'tress "eduction Anger -anagementB


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oronary $nsuIciency

$-7A)A, 7,+,,

%D*, '()*

%D*, #,-A#

-*%A"#$A) $FA"+$%


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-*%A"#$A) $FA"+$%$"",&,"'$7), A"#$A #A-A, F"%- %)('$% %F 1 %"-%", %"%A"* A"+,"*

",&$, %F AA+%-* A# H*'$%)%*

,EEE

"ecent -E$E '+ elevation in -7

R


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P

R

S

"

#


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P

R

S

"

#


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P

R

S

"

#


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P

R

S

"

#


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-*%A"#$A) $FA"+$%("'$ A",

1E ain relief

-orpine P

preload / afterloadB#emerol causes vomiting

2E %@ygen

3E $notropics

4E 7eta 7loc;ers5E Antiarrytmics

6E o ice or very ot

drin;s !E Anticoagulants

8E , and &monitoring

9E )a@atives )actulose 10E +A

11E +rom:olytic +erapy

7,F%", ,))()A"

A"#$A A""H*+H-$A


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A"#$A A""H*+H-$A"evie. onduction at.ay

"evie. te 7asics of ormal ,

%#(+$% A+HA*


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%#(+$% A+HA*

RA LA

R, L,

'A %#,

A& %#,

7(#), %F H$'

7(#),7"AH

(">$?,

(">$?,

R


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P

R

S

"

#


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A"#$A A""H*+H-$A'inus +acycardia .ave precede eac O"'

Q100 :pm

'inus 7radycardia .ave precede eac O"'L60 :pm

Atrial Fi:rillation .ave C f .avesR O"' C

normal

R


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P

R

S

"

#


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%#(+$% A+HA*

RA LA

R, L,

'A %#,

A& %#,

7(#), %F H$'

7(#),7"AH

(">$?,

(">$?,

A"#$A A""H*+H-$A


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A"#$A A""H*+H-$Aremature &entricular ontraction .ave

normal early O"'

&entricular +acycardia 3 or more &s

Asystole no cardiac activity

R


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P

S

"

#


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%#(+$% A+HA*

RA LA

R, L,

'A %#,

A& %#,

7(#), %F H$'

7(#),7"AH

(">$?,

(">$?,

A"#$A A""H*+H-$A


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A"#$A A""H*+H-$Aursing -anagement

%@ygen

omplete 7ed "est

ardioversionM de=:rillationAdminister antiarrytmics as prescri:ed

Atropine

7eta :loc;er propanolol

)idocaine ,pineprine


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EHEFE

)('


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*#

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L#

L7

S!ST/3CC3*C8L#T3,

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S!ST/3CC3*C8L#T3,

L7

%,'+$&, H,A"+ FA$)("," i f A t d i l


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"evie. of Anatomy and ysiology

7ac;.ard FailureFor.ard Failure

)eft'ided

"igt 'ided

Hypermeta:olic Failure

linical -anifestations according to +issue Ano@ia

ulmonary Hypertension'ystemic congestion

%,'+$&, H,A"+ FA$)(", #i ti


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#iagnostics

ursing -anagement oals

1E A"#$A )%A# ",'+ A# ',#A+$%

2E A"#$A %+"A+$)$+* H"%%+"%$' DIGITALIS

$ncrease in force of contraction monitor serum >

M$ if H" LMC 60 :pm #$$+A)$' +%D$$+*

%,'+$&, H,A"+ FA$)(",


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%,'+$&, H,A"+ FA$)(",3E '%#$(- ",A7'%"+$% A# F)($#

",+,+$%

DIURETICS ( Thiazide, Loop, K-sparing)

-measure U-!eigh pa"ien"

-!a"#h $or s%s& o$ e'e#"ro'"e ima'an#e

-#$,+ Sodium Res"ri#"ed (*+gm%da)

%,'+$&, H,A"+ FA$)(",


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%,'+$&, H,A"+ FA$)(",4E ",&,+$% %F %-)$A+$%'

$ntracta:le HF

ulmonary edema

ulmonary $nfarction-yocardial $nfarction

#igitalis +o@icity

ardiac Arrytmia

neumonia

()-%A"* ,#,-A, S


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,mergencyS

Fluid into te alveoli :ronci / :roncioles

'M'D

Tof HF

#yspnea

oug .it pin; froty sputum

()-%A"* ,#,-A-AA,-,+


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-AA,-,+

%@ygenation

Assist in $ntu:ation

"otating tourniNuet

le:otomy

& monitoring

H*,"+,'$%


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A+,%"* '7 mmHg #7 mmHg

ormal L120 and L180

reH 120139 or 8089

H 'tage 1 140159 or 9099

H 'tage 2 QC160 or QC100

H*,"+,'$%Assess for -a


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Assess for -a


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"erima :asi$dr - Arman asution 'p#

Documents

1. CARDIOLOGY Decompensatio