CONGESTIVE CONGESTIVE HEART FAILUREHEART FAILURE

OKTAVIANI HALIM030.09.178

PATIENT IDENTITY PATIENT IDENTITY Name : Mr. Edi SunardiAge : 55 years oldSex : ManAddress : Teluk jambe, KarawangReligion : MoeslemEthnic : SundaneseMarital status : MarriageEducation : Senior High schoolOccupation : EmployeAddmited : August 1th, 2013

PRESENT ILLNESSPRESENT ILLNESS

MAIN COMPLAINTMAIN COMPLAINT

Shortness of breath since 3 days before admission, continuously, affected by activities and position, sleep with 3 pillows, sudden awakening in the night.

ADDITIONAL COMPLAINTADDITIONAL COMPLAINT

•Pain in the upper middle stomach since 3 days before admission,dull, continuously.•Fatigue is present even at rest since 3 days before admission.•Dizzines since 3 days before admission•Nausea since 1 week ago, intermittently, affected by drinking and eating•Vomiting since 3 days before admission, intermittently, yellow, food in the vomit content, no blood and no mucus. Fever 3 days before admission.

ADDITIONAL COMPLAINTADDITIONAL COMPLAINT

•Deterioration of visual acuity since 3 weeks before admission•Excessive thirst•Excessive hunger•Increased urination

PAST MEDICAL RECORDPAST MEDICAL RECORD

HISTORY OF THE DISEASEHISTORY OF THE DISEASE

FAMILY HISTORYFAMILY HISTORY

HABITS HISTORYHABITS HISTORY

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

VITAL SIGN

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

THORAX - HEARTTHORAX - HEART

THORAX - PULMOTHORAX - PULMO

ABDOMENABDOMEN

+ ++ -

- -- -

EXTREMITY EXAMINATIONEXTREMITY EXAMINATION

Edema

Warm acrals

August 1st , 2013Examination Result Normal Range

Hb 12,2 g/dL 12-17 g/dLHt 34 % 37-58 %Leucocytes 18.740 /µL 5000-10000Thrombocytes 222.000/µL 150.000-450.000

Blood glucose 604 80-140

Ureum 90,8 10-45

Creatinine 1,42 0,4-1,5

LABORATORY TESTLABORATORY TEST

LABORATORY TESTLABORATORY TESTAugust 1st , 2013

CK-MB 33 U/l <24 u/l

Troponin T 1,8 <0,01mg/l

August 3th , 2013Blood glucose (fasting)

322 70-100

Blood Glucose (2 hours Post prandial)

182 <140

LABORATORY TESTLABORATORY TEST

THORAXTHORAXTHORAX PACTR > 50%

ECGECG

ECGECG

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSIS

SUGESTED EXAMINATIONSUGESTED EXAMINATION

THERAPHY (EMERGENCY ROOM)THERAPHY (EMERGENCY ROOM)O2NaCl 0,9% 1 kolf/24 hoursDobutamin 3 micro dripLovenox 2x0,6cc T.Aspilet 1x1Clopidogrel 1x5Simvastatin 1x20

FOLLOW UP AUGUST 2RD 2013FOLLOW UP AUGUST 2RD 2013S : Shortness of breath, Chest pain,

nausea 0 : bp: 140/80 mmhg

hr: 71bpmrr: 42bpmT: 36,5⁰CO2 saturation : 95-97

THERAPHYTHERAPHY

NaCl 0,9% 1 kolf/24 hoursFurosemid VCedocard 9 mg/lLovenox 2x0,6 cc (I)Captopril 3x12,5ISDN 3x5mgClopidogrel 1x1Simvastatin 1x20gOmeprazole 2x1 ampl

PROGNOSIS PROGNOSIS

AD VITAM : DUBIA AD BONAM

AD FUNCTIONAM : DUBIA AD MALAM

AD SANATIONAM : DUBIA AD MALAM

LITERATUREREVIEW

ACUTE MYOCARDIAL INFARCTION

DEFINITIONDEFINITION

Myocardial infarction (MI; ie, heart attack) is the irreversible necrosis of heart muscle secondary to prolonged ischemia

SYMPTOMSSYMPTOMSPressure, tightness, pain, or a squeezing or

aching sensation in your chest or arms that may spread to your neck, jaw or back)

A feeling of fullness, nausea, indigestion, heartburn or abdominal pain

Shortness of breathSweating or a cold sweatFeelings of anxiety or an impending sense of

doomFatigueTrouble sleepingLightheadedness or dizziness

SPECIAL CONDITIONSPECIAL CONDITION The patient may recall only an episode of indigestion as an

indication of myocardial infarction. In some cases, patients do not recognize chest pain,

possibly because they have a stoic outlook, have an unusually high pain threshold, have a disorder that impairs function of the nervous system and that results in a defective anginal warning system (eg, diabetes mellitus), or have obtundation caused by medication or impaired cerebral perfusion.

Elderly patients with preexisting altered mental status or dementia may have no recollection of recent symptoms and may have no complaints whatsoever.

Coronary artery disease

Rupture of the plaque

Build-up plaque in coronary

artery

Narrowed coronary artery

Complete/partial blocked in

coronary artery

Spill out cholesterol and other

substances into the bloodstream

A blood clot forms at the site

of the rupture

Myocardial infarction

RISK FACTORSRISK FACTORSAgeTobaccoHigh blood pressureHigh blood cholestrol or tg levelsDiabetesFamily history of heart attactLack of phisycal activitiesObesityStressIllegal drus use

TEST AND DIAGNOSISTEST AND DIAGNOSIS

PHYSICAL EXAMINATION

ECGBIOMARKER (TROPONIN T

& CK-MB)THORAX X-RAY

ECHOCARDIOGRAPHYCORONARY

CATHETERIZATIONEXCESSIVE STRESS TEST

Acute Coronary Syndromes AlgorithmAcute Coronary Syndromes AlgorithmOut-of-Hospital Care Decision 1: Does the patient have chest discomfort suggestive of

ischemia? Assess and care for the patient using the primary and secondary

surveys.

Prepare patient for hospital admission.•Monitor and support ABCs (airway, breathing, and circulation).

Take vital signs.Monitor rhythm.Be prepared to administer CPR if the need arises. Watch for it.Use a defibrillator if necessary.

•Think MONA: Administer oxygen, aspirin, nitroglycerin, and morphine, if needed.•If possible, obtain a 12-lead ECG.•Interpret or request an interpretation of the ECG.If ST elevation is present, transmit the results to the receiving hospital.•Hospital personnel gather resources to respond to STEMI.•Start filling out a fibrinolytic checklist.

Acute Coronary Syndromes AlgorithmAcute Coronary Syndromes Algorithm

In-Hospital Care

Within the first 10 minutes that the patient is in the Emergency Department (ED), work through the following:◦ Check vital signs.◦ Evaluate oxygen saturation.◦ Establish IV access.◦ Get or review a 12-lead ECG.◦ Look for risk factors for ACS, cardiac history, signs and

symptoms of heart failure by taking a brief, targeted history.◦ Perform a physical exam.◦ Complete a fibrinolytic checklist and check contraindication◦ Obtain a portable x-ray (less than 30 minutes).

Acute Coronary Syndromes AlgorithmAcute Coronary Syndromes Algorithm

Begin general treatment in the ED:Start oxygen at 4 L/min and maintain oxygen

saturation > 90%.If the patient did not take aspirin while with the

EMS provider, give aspirin (160 to 325 mg).Administer nitroglycerin, either sublingual, spray,

or IV.Give the patient morphine (IV) if pain is not

relieved by nitroglycerin.

If the patient is classified with NSTEMI or high-riskunstable angina, follow this section of the algorithm.

Start adjunctive treatments for NSTEMI, as indicated:◦ Nitroglycerin◦ Beta-adrenergic receptor blocker◦ Clopidogrel◦ Heparin (UFH or LMWH)◦ Glycoprotein IIb/IIIa inhibitor

Acute Coronary Syndromes AlgorithmAcute Coronary Syndromes Algorithm

Acute Coronary Syndromes AlgorithmAcute Coronary Syndromes Algorithm

ECG shows normal ECG or nonspecific ST-T wave changes

Consider admitting the patient to hospital or to a monitored bed in ED

Monitor ECG continually for changes in ST-T.Obtain serial cardiac markers, including troponin.Consider stress test.

CONGESTIVE HEART FAILURE

DEFINITIONDEFINITIONHeart failure develops when the heart, via

an abnormality of cardiac function (detectable or not), fails to pump blood at a rate commensurate with the requirements of the metabolizing tissues or is able to do so only with an elevated diastolic filling pressure.

HISTORY TAKINGHISTORY TAKINGExertional dyspneaOrthopneaParoxysmal nocturnal dyspneaDyspnea at restPulmonary edemaChest pain/pressure and palpitationsFatigue and weaknessNocturia and oliguriaCerebral symptoms

Framingham major criteriaFramingham major criteria Paroxysmal nocturnal dyspnea Weight loss of 4.5 kg in 5 days in response to treatment Neck vein distention Rales Acute pulmonary edema Hepatojugular reflux S3 gallop Central venous pressure greater than 16 cm water Circulation time of 25 seconds Radiographic cardiomegaly Pulmonary edema, visceral congestion, or cardiomegaly at

autopsy

Framingham – minor criteriaFramingham – minor criteriaNocturnal coughDyspnea on ordinary exertionA decrease in vital capacity by one third

the maximal value recordedPleural effusionTachycardia (rate of 120 bpm)Bilateral ankle edema

The New York Heart Association The New York Heart Association (NYHA) classification system (NYHA) classification system categorizes heart failure on a scale of categorizes heart failure on a scale of I to IV,I to IV,[4] [4] as follows:as follows:Class I: No limitation of physical activityClass II: Slight limitation of physical

activityClass III: Marked limitation of physical

activityClass IV: Symptoms occur even at rest;

discomfort with any physical activity

PATHOPHYSIOLOGYPATHOPHYSIOLOGY

DIABETES MELLITUS

HEART ATTACT

WEEKENING HEART’S PUMPING ABILITY

HEART FAILURE

HYPERTENSION FAULTY

HEART FALVE

CORONARY ARTERY DISEASE

CONGENITAL HEART

DISEASE

EXTRA WORK FOR HEART

MUSCLEOTHER

DISEASES

KILLIP CLASSKILLIP CLASS•Killip class I includes individuals with no clinical signs of heart failure

•Killip class II includes individuals with rales or crackles in the lungs, an

S3, and elevated jugular venous pressure.

•Killip class III describes individuals with frank acute pulmonary edema.

•Killip class IV describes individuals in cardiogenic shock or hypotensioN

(measured as systolic blood pressure lower than 90 mmHg), and

evidence of peripheral vasoconstriction (oliguria,cyanosis or sweating).

Killip class I:81/250 patients;32% (27–38%).Mortality rate was found to be 6%.(current 30 day mortality 2.8)

Killip class II:96/250 patients;38% (32–44%).Mortality rate was found to be 17%.(current 30 day mortality 8.8)

Killip class III:26/250 patients;10% (6.6–14%).Mortality rate was found to be 38%.(current 30 day mortality 14.4)

Killip class IV:47/250 patients;19% (14–24%).Mortality rate was found to be 67%.

TheraphyTheraphyO2Ventilasi non invasiveMorphin & analog morphinLoop diuretikaVasodilatorNitratObat-obat inotropik

DIABETES MELLITUS

KRITERIA DIAGNOSIS DM1 Gejala klasik DM + GDS ≥200mg/dl

Atau

2 Gejala klasik DM + GDP ≥126mg/dl Atau

3 Kadar Glukosa darah 2 jam pada TTGO ≥200mg/dl

KOMPLIKASI KRONIK DMKOMPLIKASI KRONIK DMMIKROVASKULAR:

GINJAL RETINA MATA

MAKROVASKULAR: JANTUNG KORONER PEMBULUH DARAH KAKI PEMBULUH DARAH OTAK

NEUROPATI : MIKRO DAN MAKROVASKULAR

RENTAN INFEKSI : MIKRO DAN MAKROVASKULAR

PRINSIP PENATALAKSANAAN DMPRINSIP PENATALAKSANAAN DM

OBAT HIPERGLIKEMIK ORAL

INSULIN

OBAT HIPERGLIKEMIK ORALOBAT HIPERGLIKEMIK ORALPEMICU SEKRESI INSULIN

PENAMBAH SENSITIVITAS TERHADAP INSULIN

PENGHAMBAT ALFA GLUKOSIDASE

GOLONGAN INKRETIN

PEMICU SEKRESI INSULINPEMICU SEKRESI INSULIN

GOLONGAN GLINID

REPAGLINIDNATEGLINID

GOLONGAN SULFONILUREA

KhlorpropamidGlibenklamidGliklasidGlikuidonGlipsidGlimepirid

Penambah sensitivitas terhadap Penambah sensitivitas terhadap insulininsulin

Biguanid

Thiazolindion

LAIN-LAINLAIN-LAINPENGHAMBAT ALFA

GLUKOSIDASE/ACARBOSE

GOLONGAN INKRETIN◦INKRETIN MIMETIK◦PENGHAMBAT DPP IV

TERAPI INSULINTERAPI INSULINIndikasi:

Dm tipe 1Dm tipe 2 bila:

Pengobatan oral tidak mencapai targetKeadaan stres berat, sperti pada infeksi berat, tindakan pembedahan, infark miokard akut atau stroke

Dm gestasionalKADHHSDm yang membutuhkan suplemen tiggi kaloriGangguan fungsi ginjal atau hati yang beratKI/alergi obat oral

KARAKTERISTIK INSULIN YANG KARAKTERISTIK INSULIN YANG ADA DI INDONESIAADA DI INDONESIACEPAT

◦Novorapid, apidra, humalog

SINGKAT◦Actrapid, humulin-R

MENENGAH◦Insulatard◦Humulin N

KARAKTERISTIK INSULIN YANG KARAKTERISTIK INSULIN YANG ADA DI INDONESIAADA DI INDONESIACAMPURAN

◦Mixtard 30, Humulin 30/70, Novomix 30\

BASAL◦Lantus, levemir

THANK YOUTHANK YOU