CONGESTIVE HEART FAILURE CONGESTIVE HEART FAILURE

(CHF) NYHA III e.c Coronary (CHF) NYHA III e.c Coronary

Artery Disease (OMI Artery Disease (OMI

Anteroseptal)Anteroseptal)

Supervisor :

dr. Pendrik Tandean, SpPD-KKV.FINASIM

By :FathlinaC 111 08 212

Patient Identity

• Name : Mrs. T• Gender : Female• Age : 68 years old

Anamnesis (1)• Chief Complaint : Shortness of breath

• Shortness of breath has been experienced since 2 years ago and worsened from yesterday. It was experienced while doing minimal activity such as walking to the bathroom and relieved with resting. There is complain of sudden shortness of breath during night time that cause her to be awaken. He also had to use at least 2 pillows to sleep during night time.

Anamnesis (2)• There is also history of chest pain which has been experienced since 2 years ago. Chest pain was felt like being as punch like pain spread to the neck until her arms and last for less than 5 minutes of duration. Chest pain was also relieved by resting.

• There is no complaint of palpitation, fever, cough, nausea, and vomit.

• There is no complaint of urination and defecation.

Past Medical History• There is history of being admitted to the hospital 2 times with the same complaint of shortness of breath.

• There is history of hypertension since 10 years ago but she doesn’t take the drugs regularly.

• She never smoking and consumption alcohol.• There is no history of fever, congenital heart disease, thyroid disease, and diabetes mellitus.

• There is also no family history with cardiovascular disease and thyroid disease.

Risk Factors

• Cigarette smoking (-)• Alcohol consumption(-)• Hypertension(+)• Diabetes Mellitus(-)• Cardiovascular disease (+)• Thyroid disease (-)• History of cardiovascular disease and thyroid disease in family (-)

Physical Examination

General Status:• Severe ill• Nutritional Status: Good • Consciousness: Conscious

Vital Signs:• Blood Pressure : 120/70 mmHg• Pulse Rate : 76 bpm, regular• Respiratory Rate : 28 bpm• Temperature : 36.7 °C

Head and Neck Examinations:• Eye : Conjunctiva anemic (-/-), sclera icteric (-/-)• Lip : cyanosis (-)• Neck : No mass, no tenderness, JVP : R + 3 cmH2O

Chest Examination• Inspection : Symmetric left=right • Palpation : No mass, no tenderness, vocal fremitus

left=right• Percussion : Sonor left = right, lung-liver border in ICS

VI right anterior• Auscultation: Breath sound : vesicular Additional sound : Ronchi + +

Wheezing -/- + + + ++ +

Physical Examination

Cardiac Examination•Inspection : Ictus cordis was not visible•Palpation : Ictus cordis was not palpable•Percussion :Right heart border in right parasternal line, left heart border two fingers from left midclavicular line ICS VI.•Auscultation : Heart sound : S I/II regular, no gallop, no additional sound

Physical Examination

Abdominal Examination

• Inspection : flat, following breath movement

• Auscultation : Peristaltic sound (+), normal

• Palpation : No mass, no tenderness, no palpable

liver and spleen

• Percussion : Tympani (+), ascites (-)

Extremities Examination

• Pretibial edema -/-

• Dorsum pedis edema -/-

Physical Examination

Electrocardiography(ECG)Electrocardiography(ECG)

Interpretation:•Rhythm:No sinus•HR/QRS rate:75x/minutes•Regularity: regular•P wave & PR interval: 0,08s and 0,16 s•QRS Complex: 2 small squares(0.08s), Q pathologies in V1,V2, V3. VES (+)•Axis: Normal•ST segment: Normal•T wave: Normal

Conclusion of ECG• Sinus rhythm. • HR 75x/minutes.• Normoaxis.• P wave normal.• Q pathologies in V1, V2, and V3 (OMI Anteroseptal).

• VES (+).• T wave normal

Chest X-rays

Conclusion :Cardiomegaly, pulmonary edema with dilatation and elongation aortae

Laboratory Finding

Test Result Normal value

WBC 7.9/ul 4.0 – 10.0 x 103

RBC 3.96/µl 4.0 – 6.0 x 106

HGB 11.6 gr/dl 12 – 16

HCT 36.0% 37 – 48

PLT 221 000/µl 150 – 400 x 103

Complete Blood Count

Electrolyte

Test Result Normal value

Na 149 mmol/l 136-145

K 4.1 mmol/l 3.5-5.1

Cl 117 mmol/l 97-111

Laboratory FindingTest Result Normal value

GDS 131 mg/dl131 mg/dl <140

Ureum 70 mg/dl 10 – 50

Creatinine 1.0 mgr/dl < 1.3

SGOT 35 u/l <38

SGPT 36 u/l <41

Total CholHDL CholLDL Chol

150 mg/dl 43 mg/dl77 mg/dl

<200> 55 < 130

TG 76 mg/dl <200

Blood Chemistry

Cardiac Enzymes

Test Result Normal value

CK 64 U/L <167

CK-MB 9 U/L <25

Troponin-T <0.1 Negative

Diagnosis

•CHF NYHA III e.c CAD (OMI anteroseptal)

Management

O2 5 lpm

IVFD NaCl 0.9% 10 dpm

Inj. Furosemide 40 mg/12 jm/ IV

Captopril 12,5 mg 1-1-1

Aspilet 80 mg 0-1-0

Fasorbid 10 1-1-1

Alprazolam 0.5 mg 0-0-1

Planning

• ECG control

• Echocardiography

DISCUSSIONCongestive Congestive HeartHeart Failure Failure (CHF)(CHF)

Definition

Other Causes

Arrhythmias Valvular heart diseaseCongenital heart diseasePericardial diseaseHyperdynamic circulationAlcohol and drugs(chemotherapy)

Main Causes

Ischemic heart disease (35%-40%)Cardiomyopathy(dilated) (30-40%)Hypertension ( 15-20%)

Etiology of Heart Failure

Major Criteria Minor Criteria

Paroxysmal Nocturnal

Dyspnea

Cardiomegaly

Gallop S3

Hepatojugular reflux

Increased of JVP

Rales or ronchi

Acute pulmonary edema

Prolonged circulation time(> 25

sec)

Weigh loss ≥ 4,5 kg in 5 days in

response to treatment of CHF

Extremity edema

Nocturnal cough

Decreased vital

pulmonary

capacity (1/3 of maximal)

Hepatomegaly

Pleural effusion

Tachycardia (≥ 120bpm)

Dyspnea d’effort

Classification of CHF

Pathophysiology of CHF

Treatment of CHF

Coronary Artery Disease• Coronary artery disease is a narrowing of the

small blood vessels that supply blood and oxygen to the heart.

• (CAD) occurs when the arteries that supply blood to the heart muscle (the coronary arteries) become hardened and narrowed due to buildup of a material called plaque (plaque) on their inner walls. This is known as atherosclerosis

• Eventually, blood flow to the heart muscle is reduced, and, because blood carries much-needed oxygen, the heart muscle is not able to receive the amount of oxygen it needs.

Causes Coronary Artery Disease

• Coronary artery disease (CAD) is caused by atherosclerosis (the thickening and hardening of the inside walls of arteries). Some hardening of the arteries occurs normally as a person grows older.

• In atherosclerosis, plaque deposits build up in the arteries. Plaque is made up of fat, cholesterol, calcium, and other substances from the blood. Plaque buildup in the arteries often begins in childhood.

Plaque in the arteries can be:• Hard and stable. Hard plaque causes the artery walls to thicken and harden. This condition is associated more with angina than with a heart attack, but heart attacks frequently occur with hard plaque.

• Soft and unstable. Soft plaque is more likely to break open or to break off from the artery walls and cause blood clots. This can lead to a heart attack.

Risk factors

INVESTIGATION• Electrocardiogram (ECG)• Treadmill Test• Echocardiography• Coronary Angiography• Multi-Slice Computed Tomography Scan (MSCT)

• Cardiac Magnetic Resonance Imaging (Cardiac MRI)

• Radionuclear Medicine

TREATMENT (1)

Lifestyle Changes• Eat a healthy diet • Quit smoking, if you smoke

• Exercise • Lose weight, if you are overweight or obese

• Reduce stress

Medicines• Cholesterol-lowering medicines

• Anticoagulants• Aspirin• ACE inhibitors• Beta blockers• Calcium channel blockers

• Nitroglycerin• Long-acting nitrates

TREATMENT (2)

Special Procedures• Angioplasty (PTCA)• Coronary artery bypass surgery• Enhanced External Counterpulsation (EECP)Cardiac Rehabilitation• Exercise training• Education, counseling, and training

THANK YOU

Terima Kasih…….

Danke….

Matur Nuwun….

Syukron….

Gracias…..

AriGato….