Cardiovascular Department Case Report

Faculty of Medicine August 2015

Universitas Hasanuddin

Congestive Heart Failure

NYHA III and Non ST-segment
Elevation Myocardial Infarction
By:
Nur Amaliah Idrus
C11111010

Supervisor:
dr. Pendrik Tandean, Sp.PD-KKV.FINASIM
 Patient’s Identity
• Name : Mrs. P
• Age : 57 years old
• MR : 721154
• Address : Pinrang
• Admitted : 4th of August 2015
 History Taking

• Chief complain: chest pain

• Suffered since a day before
• Blunt pain, radiation (-)
• Provoked by activity (-)
• Cold sweat
• Shortness of breath (+)
• DOE (+)
• PND (+)
• Orthopnea (+)
• Cough (+)
• Epigastric pain (+), nausea (+), vomit (+)
 History Taking

• Hypertension (+) since 10 years ago (consumes

captopril 25 mg/day regularly)
• Mellitus diabetic (-)
• Previous heart disease(-)
• Family history of heart disease (-)
• Smoking (-), alcoholic (-)
 Risk Factors

• Modifiable:
– Obesity,
– Hypertension
• Non modifiable:
– Age (57 y.o)
 Physical Examination
• General state:
– moderate illness, obesity, compos mentis
• BMI: 25,9 kg/m2 (overweight)
• Vital signs:
– BP: 120/80 mmHg
– HR: 112 bpm
– RR: 32 x/minute
– Axillary temperature: 36,5oC
 Physical Examination
• Head : anemic (-) icteric (-)
• Neck : JVP R+3 cmH2O,
• 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 not visible
– Palpation : ictus cordis not 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 (-)
ECG

Sinus rhytm,
HR 110 bpm,
normoaxis, ST-
depression on V4-
V6; poor R-wave
progression on
V1-V3

Conclusion:
Anterolateral
ventricle wall
infarction
 Laboratory Finding
Findings
4th of August 2015
Laboratory Findings
RadiologyRadiology
FindingsFindings

• Chest X-Ray
– Cardiomegaly followed by
pulmonary edema sign
– Pleural reaction
– Dilatatio et atherosclerosis
aortae
– Right diaphragm elevation
Radiology Findings

• Abdominal
USG
– Right pleural
effusion
 Assessments
• Congestive Heart Failure NYHA III
• Non-ST-Segment Elevation Myocardial Infarction

Planning
• Echocardiography
• Coronary Angiography
 Management

1. Oxygen 4 lpm via nasal cannula

2. IVFD NaCl 0,9% 500 cc/24 hours/IV
3. Furosemide 20 mg/24 hours /IV
4. Aspilet 80 mg/24 hours oral
5. Clopidogrel 75 mg/24 hours /oral
6. Farsorbid 10 mg/8 hours /oral
7. Simvastatin 40 mg/24 hours/oral
 DISCUSSION
1. Congestive Heart Failure
2. NSTEMI
 CONGESTIVE HEART FAILURE

Definition
• Forward failure
• Backward failure
• Or both
CONGESTIVE HEART FAILURE

Causes
 CONGESTIVE HEART FAILURE

Causes
• Myocard dysfunction:
– CAD
– Cardiomyopathy
– Myocarditis and rheumatic heart disease
– Infiltrative disease
– Iatrogenic
• Mechanic dysturbance
– Pressure overload
– Volume overload
– Filling defect
 CONGESTIVE HEART FAILURE

Pathophysiology
Case:
History Taking:
- Shortness of breath
- DOE (+)
- PND (+)
- Orthopnea
- Cough

Physical Examination
- JVP increasing
- Rales

Radiology Findings
- Chest X-ray: cardiomegaly followed by pulmonary edema sign
- Abdominal USG: right pleural effusion
Case:
History Taking:
- Shortness of breath
- DOE (+)
- PND (+)
- Orthopnea
- Cough

Physical Examination
- JVP increasing
- Rales

Radiology Findings
- Chest X-ray: cardiomegaly followed by
pulmonary edema sign
- Abdominal USG: right pleural effusion
 CONGESTIVE HEART FAILURE

Classification

New York Heart Association (NYHA)

 CONGESTIVE HEART FAILURE

DIAGNOSIS
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;
10. Body mass decreasing
 CONGESTIVE HEART FAILURE

DIAGNOSIS
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.
 CONGESTIVE HEART FAILURE

Definitive Diagnosis

At least 2 major criteria

OR
1 major criteria + 2 minor criteria concurrently
 NSTEMI

Definition
Case
History Taking:
- Chest paint
- Blunt
- Suddenly
- Provoked by activity (-)
- Cold sweat

ECG:
- ST-segment depression
- Poor R-wave progression

Laboratory Findings:
- Cardiac biomarkers/enzymes
increasing
 NSTEMI

Pathophysiology
 NSTEMI

Diagnosis
Diagnosis
WHO criteria
At least 2 points:
- Typical chest pain
- ECG record
- Cardiac biomarkers/enzymes increasing
 NSTEMI

Therapy
Therapy
Goal
• Hemodynamic stabilization
• Pain relief
• Reperfusion
• Prevent complications
Thank You