Congestive Heart Failure (CHF)

NYHA II e.c Coronary Arterial

Disease
Supervisor:
dr. Abdul Hakim Alkatiri, Sp.JP, FIHA
PRESENTED IN THE CONTEXT OF THE CLERKSHIP
CARDIOVASCULAR DEPARTMENT
MEDICAL FACULTY
HASANUDDIN UNIVERSITY
2013
Presented by:
Eka Budi Prasetya C11108130
CASE REPORT CARDIOLOGY DEPARTMENT
PATIENTS IDENTITY
Name : Mr. A
Age : 63 years old
Gender : Male
MR : 600089
Day of Admission : 20/3/2013

HISTORY TAKING
CHIEF COMPLAINT: Breathing difficulty
Anamnesis:
It was felt since 1 year ago and got worsen 2 weeks before
admitted to the hospital. 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. The patient
also complains chest pain, felt on the left side of the chest
with the characteristics of heavy feeling on the chest, duration
of pain was < 30 minutes, did not radiate to the left arm and
to the back. The pain exacerbates with exercise and lessen
with rest. Dyspnea on effort (+), Orthopnea (-), Paroxysmal
Nocturnal Dyspnea (+), Cough (+) intermittent since 1 year
ago with sputum of white coloured. Fever (-) Nausea (-) Vomit
(-) Palpitation (-), Cold sweats (+). Defecation and urination:
normal.

PAST MEDICAL HISTORY
History of diabetes (-)
History of hypertension (+) since 4 years ago
with controlled therapy.
History of dyslipidemia is denied.
History of hyperuricemia (+)
History of smoking (+) since 45 years ago but
stopped 1 month before admitted to the
hospital. 1 box per day.
History of asthma (+)
History of cardiovascular disease in family (-)
RISK FACTORS
Non-modified
Gender:
Male
Age > 45
years old
Modified
Cigarette
smoking
Hipertension
PHYSICAL EXAMINATION
General Status:
Moderate illness/ Well nourished/ Conscious
Nutritional Status: Normal (BMI: kg/m)
Weight : 60 kg BMI: 23.4 kg/m
2

Height : 160 cm

Vital Signs:
Blood Pressure : 130/60 mmHg
Pulse Rate : 80 bpm
Respiratory Rate : 25 bpm
Temperature : 36.7
0
C
Head and Neck Examinations:
Eye : Conjunctiva anemic (-/-), Sclera icteric (-/-)
Lip : Cyanosis (-)
Neck : JVP R +2 cmHO

Chest Examination
Inspection : Symmetric between left and right chest.
Palpation : No mass, no tenderness.
Percussion : Sonor between left and right chest,
lung-liver border in ICS IV right anterior.
Auscultation: Respiratory sound: Vesicular
Additional sound :Ronchi +/+,Wheezing /-
Cardiac Examination
Inspection : Heart apex was not visible
Palpation : Heart apex was not palpable
Percussion : Right heart border in right
parasternal line, left heart
border in left midclavicular
line ICS V.
Auscultation : Heart Sounds : S I/II regular,
murmur (-) gallop(-)
Abdominal Examination
Inspection : Flat, follows breathing
movement
Auscultation : Peristaltic sound (+), normal
Palpation : No mass, no tenderness, no
palpable liver or spleen.
Percussion : Tympani (+)

Extremities Examination
Pretibial edema -/-
Dorsal pedis edema -/-
ELECTROCARDIOGRAM (ECG)
ECG Interpretation
Rhythm : Sinus rhythm
HR / QRS rate : 75 bpm
Axis : Normoaxis
Regularity : Regular
P wave : 0.08 s (N: 0.08-0.11 s)
PR interval : 0.12 s (N: 0.12-0.20 s)
QRS complex : 0.08 s (N: 0.06-0.11 s)
Q pathologies : II, III, AFV
ST segment : Normal
T wave : T inverted V1-V3
Conclusion : Sinus rhythm, HR 75 bpm, OMI
inferior.
Conclusion:
-Cardiomegaly
(CTI= >0.5)
-Dilatatio et Elongatio
aortae

CHEST X-RAYS 20/3/2013
LABORATORY FINDINGS
WBC 11.35 x 10/uL GOT 110 U/L
RBC 4.41 x 10/uL GPT 43 U/L
HB 12.8 g/dL Electrolytes (Na, K, Cl) 137, 4.0, 137 mmol
HCT 40.4 % Total Cholesterol 186 mg/dL
PLT 309 x 10/uL LDL Cholesterol 131.6 mg/dL
GDS 73 mg/dL Triglyceride 72 mg/dL
Ur 31 mg/dL HDL Cholesterol 40 mg/dL
Cr 1,2 mg/dL Uric Acid 9.1 mg/dL
Troponin T 1722
ECHOCARDIOGRAM 27/2/2013
Description of Wall Motion, Masses,
Valves, Pericardium
Dilated LA
LVH (+)
Decrease LV Contractility, EF 50 %
Global Hypokinetic
Heart valves:
Mitral: MR trivial.
others: Normal
E/A<1
TAPSE 1,8cm
Conclusion:
Systolic and
diastolic
dysfunction LV
ec CAD
Global
hypokinetic EF
50 %.
CORONARY ANGIOGRAPHY 4/3/2013
Cannulation of LCA and RCA angiography shows:
LM : Normal
LAD : Diffuse stenosis prox-distal, small
vessel, 80% stenosis after D1, 75-80% stenosis
after D2
LCX : Proximal stenosis 80-90%, small vessel
RCA : Proximal total occlusion, distal filled
from LCX
Conclusion: CAD 3 VD, small vessel
Suggestions: Conservative
WORKING DIAGNOSIS
CHF NYHA II ec CAD
(miocard infarction inferior)
NSTEMI
MANAGEMENT
O
2
5 lpm
IVFD NaCl 0.9%
10 dpm
Inj. Furosemide 40
mg/12 jm/ IV
Fasorbid 10 mg 1-
1-1

Aspilet 80 mg 0-1-
0
Captopril 12,5 mg
1-1-1
Alprazolam 0.5 mg
0-0-1

DISCUSSION
DEFINITION
Heart is 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
Heart Failure
The state in which abnormal
circulatory congestion occurs as
the result of heart failure.
Congestive
Heart Failure

Other Causes

Arrhythmias
Valvular heart disease
Congenital heart disease
Pericardial disease
Hyperdynamic circulation
Alcohol 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 deffort


Classification of CHF
Pathophysiology of CHF
Plaque in
coronary artery
Blood flow to
heart muscle is
reduced. Heart
muscle lacking of
oxygen
Ischemia of heart
muscle can lead to
myocardial
infarction
The heart muscle
cant pump
adequately
Pulmonary edema
Abnormal Heart
rhythm
Symptomatic
Congestive Heart
Failure
Treatment of CHF
CAD
CAD
ACS
UAP NSTEMI STEMI
Stable
Angina
Pectoris
Definition
Acute myocardial infarction (AMI) is an
irreversible necrosis of heart muscle due to
prolonged ischemia, which is suddenly
happened.

Imbalance in oxygen supply and demand, which
is most often caused by plaque rupture with
thrombus formation in a coronary vessel,
resulting in an acute reduction of blood supply to
a portion of the myocardium.


DIAGNOSIS
WHO Diagnostic Criteria:
Clinical history of ischemic type chest
pain lasting >20 minutes.
Changes in serial ECG tracings.
Rise and fall of serum cardiac biomarkers
such as creatinine kinase-MB fraction and
troponin.
Oxford Handbook of Clinical Medicine 6
th
Edition
CLINICAL MANIFESTATIONS
MANAGEMENT
Coronary Heart Disease in Clinical Practice
THANK YOU