KONSULEN: Dr. dr. Idar Mappangara, SpPD, SpJP.FIHA.

FINASIM PRESENTER: NOR HAZIRAH BINTI OMAR C 111 09 846

IDENTITY OF PATIENT
Name : Mr. R Age : 64 y.o Gender : Male Address : Daya MR : 443141 Date of admittance : 9 September 2013

ANAMNESIS Chief Complaint :

Shortness of breath (SOB) Brief Anamnesis : The onset of SOB was 1 month before admitting in hospital. It worsens 1 day before admitting in hospital. It worsens during any physical activities such as lifting up things (DOE). He also experiences SOB whenever he lies down and with mild exertion. Patient complains that he often wakes up in the middle of night and gasps for air (PND) and he feels better if use two to three pillows while sleeping (orthopnea). He says that wheather does not influence SOB.

ANAMNESIS
Patient complaints that his both legs was swollen.

The onset was 1 week before admitting in hospital. Cough (+), white serous, appears since 1 week ago Chest pain (-), History of chest pain (+), 10 years ago, doctor advise the patient to do catheterization to put in two stent but the patient refuse to do so. Fever (-), History of fever (-) Nausea (-), Vomit (-)

PAST MEDICAL HISTORY

History of shortness of breath in June 2013 (+) was

admitted in hospital Hypertension (-) Diabetes mellitus (-) Cigarette smoking (+) 20 years

Present status: Moderate illness / Well-nourished / Conscious Vital signs: BP : 100/70mmHg HR : 92bpm RR : 36x/min T : 36,5C

Regional status
Head Examination - Eyes : Anemis (-), Icterus (-) - Lip : Cyanosis (-) - Neck : JVP R +2 cmH2O, enlargement of thyroid gland (-) Chest Examination
- Inspection - Palpation - Percussion : Symmetric sinistra et dextra : No mass, no tenderness, VF sinistra = dextra : Sonor sinistra et dextra Lung-liver border in ICS VI right anterior - Auscultation : Breath Sound = Bronchovesicular Additional Sound = Rh , Whz -/-

 Cardiac Examination
Inspection : Ictus cordis not visible. Palpation : Ictus cordis not palpable Percussion : Right heart border in right parasternal line, left heart border in left midclavicle line ICS V. Auscultation : Heart Sounds = S I/II regular , murmur (-)

 Abdominal - Inspection

: flat, following breath movement, ascites (+) - Auscultation : peristaltic sound (+), normal - Palpation : liver unpalpable spleen unpalpable - Percussion : shifting dullness (+)

Extremities - Oedema pretibial +/+ - Oedema dorsum pedis +/+ - Cyanosis (-), Clubbing finggers (-)

ELECTROCARDIOGRAPHY

Intrepetation of ECG :
Rhythm Heart rate

Regularity
PR interval P wave

Axis
Complex QRS

Duration QRS
T wave Conclusion

: Sinus : 104 bpm : Reguler : 0,08 : Normal : RAD (180) : The height of R wave > S wave at V1 : Pathologic Q wave at V2 V4 : 0,08 : inverted at V1 V3 : Sinus tachicardia, HR 104/mnt, RAD, RVH, OMI anteroseptal, low voltage

Types of test Routine Blood Test

Results WBC 7,26 x 10^3/uL PLT 121 x 10^3/uL RBC 5,2 x 10^6/uL HGB 15,9 HCT 24,7

Normal Value 4,00-10,00 150-400 4,00-6,00 13,0-16,0 37,0-48,0 76 52 1,1 26 16 51 6 37 7,9 2,4 110 10-50 <1,3 <38 <41 200 >55 <130 200 3,5-7,0 3,3-5,0 g/dL % mg/dl mg/dl mg/dl U/L U/L mg/dl mg/dl mg/dl mg/dl mg/dl gr/dl

Blood Chemistry

GDP Ur Cr SGOT SGPT Chol Total Chol HDL Chol LDL Uric Acid Albumin

Trigliseride 75

Types of test Cardiac Enzyme

Results CK 60

Normal Value <190

CKMB Trop-T
Electrolytes Na K Cl

20 0,019
130 4,2 104

<24 <0,023 ug/L

<655 ug/L 136-145 3,5-5,1 97-111

D-Dimer 6650

CHEST-XRAY
Conclusion: Cardiomegaly with signs of pulmonary edema Dilatation of aortae Right pleural effusion

USG
Bilateral Pluera Effusion

especially at right Ascites

ECHOCARDIOGRAPHY
LV systolic function decreased EF 38% LVH (-) Dilatation all cardiac space Akinatic anterio septal, hypo kinetic inferio septal, others segment hypo kinetic

RV function good, TAPSE 2,1 cm

AR Mild, MR + TR + PR Moderate E/A > 1 pseudo normalization PH Moderate mPAP 50 mmHg

WORKING DIAGNOSIS
1. Congestive Heart Failure NYHA III ec CAD 2. Hipoalbumin

MANAGEMENT
Heart Diet IVFD NaCl 0,9% 10 drips/min O2 2 4 liter/min Furosemide 200mg/24h/IV Aspilet 80mg 1-0-0 Farsorbid 10mg 1-1-1 Captopril 6,25mg 1-1-1 Alprazolam 0,5mg 1-0-0 Simvastatin 20mg 0-0-1 Laxadin Syrup 0-0-2C Infus albumin 20% 1 bottle/24 hours

PLANNING
ECG Control
Chest X-Ray

Lab Examination

Heart Failure

Heart no longer able to pump an adequate supply of blood in relation to the venous return and in relation to the metabolic needs of the body tissues at the particular moment The state in which abnormal circulatory congestion occurs as the result of heart failure.

Congestive Heart Failure

Ong, WT; Patacsil, GB. Cardiology Blue Book: 148

Etiology
Ischemic heart disease
Valve disease Hypertensive heart disease Cardiomyopathy Coronary artery disease

NYHA CLASSIFICATION
Classification NYHA I Description

-No limitation o f physical activity -No symptoms with ordinary exertion -Slight limitation of physical activity - Ordinary activity causes symptoms
-Marked limitation of physical activity -Less than ordinary activity causes symptoms -Asymptomatic at rest

NYHA II

NYHA III

NYHA IV

-Inability to carry out any physical activity without discomfort -Symptoms at rest

Signs and Symptoms

Logo The National Heart, Blood, and Company Lung Institute. cited from http://fromyourdoctor.com/.Last updated June 7, 2

Diagnosis

NB : To establish a clinical diagnosis of congestive heart failure by these criteria, at least one major and two minor criteria are required.

TREATMENT
Managing preload Managing contractility
Inotropic agents : Cardiac glycosides B- adrenergic Phosphodiesterase inhibitors Diuretics venodilator

Managing afterload
Ca2+ channel blockers Anti adrenergic Vasodilators

Neurohormonal modulation

blockers ACE inhibitors Angiotensin receptor blockers

CORONARY ARTERY DISEASE

DEFINITION
Condition in which plaque builds up inside

the coronary arteries. These arteries supply oxygen-rich blood to the heart muscle.

CAUSES
The major underlying cause is atherosclerosis. It is a slow, progressive disease which begins

in childhood and takes decades to advance. It occurs when plaque builds up in the arteries. The buildup of plaque occurs over many years. Over time, plaque hardens and narrows your coronary arteries. This limits the flow of oxygen-rich blood to your heart muscle.

Endothelial Injury Monocytes becomes macrophages Activate macrophages release free radicals

Oxidize LDL
Toxic to endothelium causing endothelial loss Exposure of subendothelial connective tissue to blood components Platelet adhesion & aggregation fibrin deposition Platelet release various factor Smooth muscle migrates into intima & proliferate Smooth muscle cell, macrophages & matrix accumulate LDL from the plasma

ATHEROMATOUS LESION

PATHOPHYSIOLOGY

RISK FACTOR
Modifiable:
Non-Modifiable :

- Smoking
- Dyslipidemia (Raised LDLC, Low HDL-C, Raised triglycerides) - Raised Blood pressure - Diabetes melitus - Obesity Personal History of CVD Family History of CVD Age Gender

CLASSIFICATION
Coronary Artery Disease Stable angina pectoris Acute Coronary Syndrome

Unstable angina pectoris

Q wave MI

Non Q wave MI

STEMI

NSTEMI

STEMI

NSTEMI

PATOGENESIS

Fixed Coronary Obstruction (Chronic Ischemic Heart Disease)

Unstable Plaque

Occlusive Thrombus

Sign & symptoms

Stable angina Discomfort in the chest, jaw, shoulder, back or arms, Typically elicited by exertion or emotional stress and relieved by rest or nitroglycerin. Less typically, discomfort may occur in the epigastric area. Unstable angina Angina at rest (> 20 minutes) New-onset (< 2 months) exertional angina (at least CCSC III in severity) Recent (< 2 months) acceleration of angina (increase in severity of at least one CCSC class to at least CCSC class III)

MI Prolonged chest pain Associated symptoms from the autonomic nervous system (nausea, vomiting, diaphoresis)

DIAGNOSIS
Electrocardiogram (ECG)

Echocardiogram
Stress test Cardiac catheterization or angiogram Magnetic resonance angiography (MRA)

TREATMENT
GOAL:

Improve prognosis by preventing myocardial infarction and

death

Minimize or abolish symptoms.

NON PHARMACOLOGY:
Lifestyle modification

Quit smoking Exercise regularly Lose excess weight Avoid stress

Pharmacological

Anti Ischemic

Anti Thrombotic

Nitrates Beta blockers Ca antagonist

Anti Platelet

Anti Coagulant

Aspirin Thienopiridines GPIIb/IIa inhibitor

Heparin LMWH Warfarin

THANK YOU