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