Department of CardiovascularCase ReportFaculty of MedicineMay 2015Hasanuddin UniversityCongestive Heart Failure (CHF) NYHA IIIe.c. Coronary Artery Disease (CAD)

By:Miftah Farid Asmaun

Supervisor:Dr. dr. Khalid Saleh, SpPD-KKV, FINASIM

PATIENTS IDENTITYName: Mr.YSex: MaleDate of Birth : 31-12-1939Age : 75 years old Occupation: FarmerDate of Admission: 11th May 2015Medical Record No. : 71.14.90

HISTORY TAKING

Shortness of breath

Suffered since 3 months ago but worsened about a week before admission to the hospital. Shortness of breath was precipitated by activity, lying position, and sometimes suffered suddenly during midnight. No chest pain at the moment but there is a history of repeated chest pain that occur suddenly at rest. Pain is intermittent and has tight and crushing quality. No cough, no history of cough. No fever, no history of fever. There are no nausea, vomiting, epigastric pain, and headache.

CHIEF COMPLAINTHISTORY TAKING

HISTORY TAKINGHistory of Previous Illness:1. Previously treated in RS Toraja for 2 weeks with complaint of chest pain and was diagnosed with coronary heart disease before patient is referred to RS Wahidin Sudirohusodo.2. There is no history of hypertension.3. History of diabetes mellitus is denied.4. There is history of coronary artery disease.5. There is history of smoking, 1 pack per day but had quit smoking about 8 years ago.6. There is no history of drinking alcohol.7. History of heart disease in the family is denied.

HISTORY TAKINGRisk Factors:Modified Risk Factors : - smokingNon-modified Risk Factor :- age- sex

PHYSICAL EXAMINATION

Moderate illness/ well-nourished/ compos mentis

Blood Pressure: 130/90 mmHgHeart Rate: 72 beats/minuteRespiratory Rate: 24 times/minuteTemperature: 36,6OC

GENERAL STATEVITAL STATE

PHYSICAL EXAMINATION

Head : Eye: anemic (-), icteric (-)Lip: cyanosis (-)Neck: JVP R+2 cmH2OThorax :Inspection : symmetric left=right, normothoraxPalpation : tenderness (-), tumor (-), vocal fremitus left=rightPercussion : sonor left = rightAuscultation : BS : bronchovesicular; ronchi +/+ on mediobasal of bilateral lungs; Wheezing -/-

REGIONAL STATE

PHYSICAL EXAMINATION

Heart :Inspection: ictus cordis is not observedPalpation: ictus cordis is not palpablePercussion: dull, heart borders enlargedAuscultation: regular I/II heart sound, murmur (-)Abdomen :Inspection: within normal limitAuscultation: peristaltic (+); normalPalpation: tumor (-), palpable liver and spleen (-)Percussion: tympani, ascites (+-)Extremities: edema: pretibial +/+ dorsum pedis -/-

DIAGNOSTIC EXAMINATIONElectrocardiography (ECG)

DIAGNOSTIC EXAMINATION

Interpretation:Rhythm: Sinus rhythm Heart Rate: 69 bpmAxis: normoaxisP wave: 0,04sPR interval: 0,16sQRS duration: 0,06s; poor R wave progression ST segment: within normal limitT wave: T-inverted V2-V4Conclusion: sinus rhythm, heart rate 69 bpm, normoaxis, Q-wave on V1-V3, poor R-wave progression

DIAGNOSTIC EXAMINATIONLABORATORIUM

WBC7,14 x 10 3 /LRBC5, 92 x 10 6 /LPLT329, 000/LHGB18, 0 g/dlHCT57, 4%INR1, 21PT12, 6 control 11, 7APTT26, 9 control 24, 6

DIAGNOSTIC EXAMINATIONLABORATORY TEST

Natrium 141 mmol/LKalium5, 1 mmol/LChloride 100 mmol/LTroponin T

DIAGNOSTIC EXAMINATIONPulmo : Pulmonary edema with minimal bilateral pleural effusionCardiomegaly with dilatatio et elongatio aortae

RADIOLOGY : Thorax X-ray

DIAGNOSTIC EXAMINATIONNormal left ventricle systolic functionLeft ventricle diastolic dysfunction grade 1Concentric remodelingDilatation of RA and RV

ECHOCARDIOGRAPHY

RESUMEA 75 years old man admitted to the hospital with chief complaint dyspnea, suffered since 3 months ago but worsened about a week before hospitalization. There are dyspnea on effort (DOE), paroxysmal nocturnal dyspnea (PND), and orthopnea. There is a history of chest pain occurring intermittently at rest with crushing and tighten sensation.History of previous illness:Previously treated in RS Toraja for 2 weeks with complaint of chest pain and was diagnosed with coronary heart disease before patient is referred to RS Wahidin Sudirohusodo.There is history of coronary artery disease.There is history of smoking, 1 pack per day but had quit smoking about 8 years ago.On the physical examination: general state : moderate illness/well-nourished composmentis; blood pressure: 130/90 mmHg; non-anemic; ronchi +/+ on mediobasal aspect of the lung; bilateral pretibial edema on both inferior extremities.Other examinations (EKG, laboratory test, thorax x-ray, and echocardiography) supported the diagnosis of congestive heart failure et causa coronary artery disease.

DIAGNOSIS

Congestive Heart Failure NYHA III et causa Coronary Artery Disease

MANAGEMENTO2 4 lpm via nasal canuleConnectaFurosemid 40 mg/12 hours/intravenaFarsorbid 10 mg/8 hours/oralAspilet 80 mg/24 hours/oralCaptopril 6,25 mg/8 jam/oralOmeprazole 40 mg/24 jam/oral

CONGESTIVE HEARTFAILURE

INTRODUCTIONAlong with the advancement of medical technology, since 1968, mortality rate of heart failure has been decreasing.Patients with heart failure survive for some years with the better medications.Although there is no exact number in Indonesia, with the better health facility and medications, it is predicted that the number of heart failure patient will be increased each year.

ANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGY

DEFINITIONHeart failure is an inability of the heart to pump sufficient amount of blood to fulfill the needs of body metabolism (forward failure) or that the ability to pump can only be obtained with high pressure from the blood entering the heart (backward failure), or both.

PREVALENCEAbout 1980; Framingham : age-adjusted: male = female.Framingham : incidency (age adjusted) annually: female = 0.14% and male = 0.23%.Survival rate of the women is generally better than of the men.The increased incidency was about 100% with 1 decade of increasing age, reach the number of 3% for 85 - 94 years old patients.

ETIOLOGYCoronary Artery Disease (CAD)HypertensionCardiomyopathy (dilatated, obstructed, restricted and obliterated)Valvular heart diseaseAlcohol consumptionMedicationsOthers

PATHOPHYSIOLOGYNeurohormonal mech.

PATHOPHYSIOLOGYRenin-Angiotensin-Aldosterone systemmech.

PATHOPHYSIOLOGYSympathetic mech.

CLASSIFICATIONNew York Heart Association (NYHA) Functional Classification based on severity and physical activity

DIAGNOSISDefinitive diagnosis of congestive heart failure:

At least 2 major criteria, OR1 major criteria + 2 minor criteria concurrently

DIAGNOSISMajor criteria:1. paroxysmal nocturnal dyspnea (PND) or orthopnea;2. Distended neck veins (in other than supine position);3. rales;4. Cardiomegaly seen in x-ray;5. Acute pulmonary oedema seen in x-ray;6. gallop ventricular S(3);7. Increased vein pressure > 16 cm H20;8. Hepatojugular reflux;9. Pulmonal oedema, visceral congestion, cardiomegaly found in autopsion; 10. Decreases body mass in CHF.

DIAGNOSISMinor criteria:1. Bilateral ankle oedema;2. Night cough;3. Dyspnea on regular activity;4. Hepatomegaly;5. Pleural effusion seen in x-ray;6. Decrease of 1/3 vital capacity from the maximal record;7. Tachycardia (120 bpm or more);8. Engorgement pulmonal vascularization seen in x-ray.

EXAMINATIONS1. Electrocardiography (ECG) : Q wave, abnormality of T wave and ST segment, LVH, bundle branch block, and atrial fibrillation.2.Thorax X-ray : cardiomegaly, pulmonal oedema.3.Echocardiography : assess the heart structure and function objectively.4.Haematology and biochemistry

EXAMINATIONSECG

EXAMINATIONSECG

EXAMINATIONSTHORAX X-RAY

EXAMINATIONSECHOCARDIOGRAPHY

MANAGEMENT

Education and counsellingDietSalt restrictionFluid restriction Avoid alcohol and cigarPerform regular activity which does not precipitate the symptoms.NON-FARMACOLOGIC

MANAGEMENT

1. Decrease the preload:diuretic, aldosterone receptors antagonist, nitrat2. Increase heart contractility:digitalis, ibopamin, -blocker gen.33. Decrease the afterload:ACE-I, ARB, DRI, dihydropiridin CCB4. Preventing miocard remodelling:ACE-I, ARBFARMACOLOGIC

PROGNOSIS

Prognosis depends on:ageetiologyNYHA classificationejection fraction (EF)Comorbid conditions (renal dysfunction, diabetes, anemia, hyperuricemia)Plasma natriuretic peptide concentration

THANK YOU