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