Congestive Heart Failure NYHA III Post Acute Lung Oedem
and Non ST-segment Elevation Myocardial Infarction
By:
Anggun Setyawati
C111 10 117
Supervisor:
dr. Abdul Hakim Alkatiri, SpJP
Case ReportSeptember, 2015
Cardiovascular DepartmentFaculty of MedicineUniversitas Hasanuddin
Patient’s Identity
• Name : Mr. SD• Age : 77 years old• MR : 723072• Address : Mamasa• Admitted to hospital : August 21st, 2015
History Taking
• Chief complain: Shortness of breath• Suffered since 4 years ago, get worse in 2 hours before admitted to
hospital• DOE (+)• PND (+)• Orthopnea (+)• Chest pain (+), since 2 days ago, blunt pain, radiation (-), provoked by
activity (-)• Cold sweat (+)• Cough (+), white sputum• Epigastric pain (+), nausea (-), vomit (-)
• Hypertension (+) since 10 years ago (consumes anti-hypertension irregularly)
• Diabetic mellitus(-)• Previous heart disease(+), 1 year ago• Family history of heart disease (-) • Smoking (+), alcoholic (-)
History Taking
• Modifiable: – Smoking, – Hypertension
• Non modifiable:– Age (77 y.o)– Gender (male)
Risk Factors
• General state: – moderate illness, poor-nourished, compos mentis
• BMI: 18,35 kg/m2 (underweight)• Vital signs:
– BP: 140/90 mmHg– HR: 80 bpm– RR: 26 x/minute– Axillary temperature: 36,5oC
Physical Examination
• Head : anemic (-) icteric (-)
• Neck : JVP R+3 cmH2O at 30o position
• Lung :– Inspection: symmetry left=right– Palpation : mass (-), no tenderness, normal vocal
fremity– Percussion: sonor– Auscultation : vesicular, ronchi (+), base of lung, wheezing (-)
Physical Examination
• Cor :– Inspection : ictus cordis visible– Palpation : ictus cordis palpable, thrill (-)– Percussion :
• Upper border 2nd ICS sinistra• Right border 4th ICS linea parasternalis dextra• Left border 5th ICS linea axillaris anterior sinistra
– Auscultation : heart sound I/II pure, regular, murmur (-)
Physical Examination
• Abdomen :– Inspection : flat, follows breath movement– Auscultation : peristaltic (+), normal– Palpation : liver and spleen not palpable– Percussion : tympani
• Extremities :– Edema (-)
Physical Examination
ECGInterpretationBasic rhytm : sinus Heart rate : 79 bpmRegularity : regularAxis : normoaxisMorphology P Wave : 0,08 second, biphasic on V1PR interval : 0,20 secondKompleks QRS : 0,08 second, R wave on I, II, III,aVF, V6; QS on V1-2; Rs on V3-V5ST segment : depression on V5-V6, I, aVLT wave : inverted on V3-V4
Conclusion : Sinus Rhytm, HR 79bpm, normoaxis, Non-ST elevation myocard infarct anterolateral
Laboratory Finding
August 21st, 2015
Laboratory Findings
Radiology Findings
• Chest X-Ray(August 22nd, 2015)
Cardiomegaly with dilatatio et elongatio aortae
Radiology Findings
• Abdominal USG(August 25th, 2015)– Prostate
hypertrophy– Right kidney cyst
Radiology Findings
-Left ventricle systolic and diastolic disfunction
-Segmental hypokinetic-Concentric left ventricle
hypertrophy-Mild aortic regurgitation
Echocardiography
• Congestive Heart Failure NYHA III Post Acute Lung Oedema
• Non-ST-Segment Elevation Myocardial Infarction
Assessments
1. Oxygen 4 lpm via nasal canul2. IVFD NaCl 0,9% 500 cc/24 hours/IV3. Furosemide 40 mg/8 jam/intravena4. Aspilet 80 mg/24 hour/ oral5. Clopidogrel 75 mg/24 hours /oral6. Isosorbid dinitrate 1mg/hour/syringe pump7. Isosorbid dinitrate 5mg/sublingual if pain8. Fondaparinuks 2,5mg/24 hours/subcutan
Management
DISCUSSION
1. Congestive Heart Failure2. NSTEMI
Definition
• The heart is unable to pump blood forward at a sufficient rate to meet the metabolic demands of the body (forward failure), or is able to do so if only the cardiac filling pressure are abnormally high (backward failure), or both.
CONGESTIVE HEART FAILURE
Physiology
CONGESTIVE HEART FAILURE
Physiology
CONGESTIVE HEART FAILURE
Pathophysiology
CONGESTIVE HEART FAILURE
Pathophysiology
CONGESTIVE HEART FAILURE
New York Heart Association (NYHA)
Classification
CONGESTIVE HEART FAILURE
DIAGNOSIS
Major 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 edema seen in x-ray;6. Gallop ventricular S(3);7. Increased vein pressure > 16 cm H20;
8. Hepatojugular reflux;9. Pulmonary edema, visceral congestion, cardiomegaly found in
autopsy;
Diagnosis
CONGESTIVE HEART FAILURE
DIAGNOSIS
Minor criteria:1. Bilateral ankle edema;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 pulmonary vascularization seen in x-ray.
Diagnosis
CONGESTIVE HEART FAILURE
At least 2 major criteriaOR
1 major criteria + 2 minor criteria concurrently
Definitive Diagnosis
CONGESTIVE HEART FAILURE
Treatment of HF w/ Reduce EF
CONGESTIVE HEART FAILURE
1.DiureticsElimination of sodium and water through the kidney intravascular vol. venous return preload the LV
Treatment of HF w/ Reduce EF
CONGESTIVE HEART FAILURE
2. Vasodilators- Venous vasodilators (eg nitrates) : venous capacitance venous return LV diastolic pressure & pulmonary capillary hydostatic pressure- Pure arteriolar vasodilators (eg hydralazine) : systemic vasc resistance & LV afterload ventricular muscle fiber shortening during systole stroke volume- Vasodilator both the venous & arteriolar : ACE-I & ARB
Treatment of HF w/ Reduce EF
CONGESTIVE HEART FAILURE
ACE-I & ARB
Treatment of HF w/ Reduce EF
CONGESTIVE HEART FAILURE
3. Inotropic drugs- -adrenergic agonists (eg dobutamine and dopamine)- Digitalis glycosides (digoxin)
4. -blockerbisoprolol, metoprolol, and carvedilol
Treatment of HF w/ Preserved EF
CONGESTIVE HEART FAILURE
The goals of therapy :1. The relief of pulmonary and systemic congestion2. Addressing correctable causes of the impaired diastolic
function
CaseHistory Taking:- Chest paint- Blunt- Suddenly- Provoked by activity (-)- Cold sweat
ECG:- ST-segment depression
Laboratory Findings:- Cardiac biomarkers/enzymes
increasing
Definition
NSTEMI
Pathophysiology
NSTEMI
Diagnosis
WHO criteriaAt least 2 points:- Typical chest pain- ECG record- Cardiac biomarkers/enzymes increasing
Diagnosis
NSTEMI
Therapy
Goal• Hemodynamic stabilization• Pain relief• Reperfusion• Prevent complications
Therapy
NSTEMI
Thank You