HEART FAILURE WITH REDUCED

EJACTION FRACTION
 Case presentation
History
• 62 years old Malay gentleman
• active -smoker (40 pack years)
• U/L
-Dyslipidaemia ,
- Hypertension
- DM Type 2
- IHD
• POM
-T losartan 50mg OD
-T amlodipine 5mg OD
-T aspirin 1 tab OD
-T metfomin 500mg OD
-T rosuvastatin 20mg ON
• No known food/drug allergies
Presented with :
• Shortness of breath for 2 months
- progressively worsening past 1/52

associated symptoms
• Orthopneoa for 2 months
- Been sleeping with 2 pillows for past 2 month
+ reduced effort tolerance
+ bilateral lower limb swelling
Otherwise
o no chest pain/palpitation
o no headache
o no fever/cough/runny nose/sore throat
o no vomiting/diarrhea
o no abd pain
o no headache/giddiness
o no limb weakness/numbness
o no hematuria/dysuria
o oral intake good

Covid History
o received 3 doses of covid-19 vaccine
o denies close contact with COVID-19 patients/PUI/PUS

Denied family history of IHD and sudden cardiac death

No past surgical history
Initially was brought to HPJ Kajang :

vitals upon arrival in KPJ

BP : 210/130 mmhg
HR 110
SpO2 90% under RA

ECG in KPJ: sinus tachycardia, HR 110

Trop T in KPJ: 0.045ng/mL
VBG :
pH7.36/pCO2 49/pO2 42/HCO 28.3/BE 3/lactate 1.8

Patient was given

-T plavix 300mg STAT
-T aspirin 300mg STAT

Then he was referred to HPJ for further management

Upon arrival at ED
GCS full, pink, warm peripheries, CRT < 2 second, good pulse volume, mild tachypnic, hydration good
and able to speak in full sentence

Vital :
BP 172/92
PR 103
Spo2 84 under RA
RR 24

GM 7.1
Urine dipstick: negative

Cardiovascular examination :
lung: bibasal bilateral crepitations
CVS: DRNM
P/A: soft non tender

bilateral pedal oedema upto midshin

Investigations in ED
BEDSIDE SCAN:
LUNG SCAN: B line over L4 and R4, others A profile
ECHO: moderate contractility, no pericardial effusion, LVH, LV not undervolume
abdomen: IVC >50% collapsible, no free fluid

ECG STAT: ST depression over V5 and V6, LVH, HR 98

ABG under RA: ph 7.44, Pco2 38, po2 33, HCO3 25.8, BE 1.7, Lactate 2.3
ABG under FM5L/min: PH 7.43, pco2 38, po2 66, hco3 25.2, BE 1.0, Lactate 2.1

CXR: ccardiomegaly, upper lobe diversion

ECG x1: ST depression over V5 and V6, LVH, HR 98

ECG x2: ST depression over V5 and V6, LVH, HR 103
ECG x3: LVH, HR 95
 investigations taken
FBC RP ELectrolyte LFT
HB 15.4 Urea 4.7 Ca 2.28 ALP 74
WCC 8.8 Na 137 Corr Ca 2.26 ALT 30
HCT 48.5 K 3.7 Mg 0.85 AST 45
PLT 237 Cr 95 Po4 1.00 TB 11.7
ALC 1.34 DB 2.7
IB 9.4
TP 74
Alb 41
Glo 33
 Impression at ED
1.decompensated CCF secondary to NSTEMI
(TIMI 4)

Management plan :
• 1 pint NS/24hrs
• FM5L/min
• s/c fondaparinux 2.5mg
• IV Lasix 40mg
Management :
further ix in ward
Monitor GM 4 hourly ,vital signs and
strict IO charting
Medications : - FSL/FBS/Hba1c and repeat
- T cardiprin 100mg OD ABG with lactate in ward
- T plavix 75mg OD - ECG daily and upon chest
- SC fondaparinox 2.5mg OD 5/7
pain
- T bisoprolol 1.25mg OD
- T Atorvastatin 40mg OD - ECHO inpatient
- SL GTN 1/1 PRN - allow orally as tolerated
- 1 ampoule of MgSo4 in 100cc NS over 4 - cardio referral upon
hours
discharge
- IV lasix 40mg stat and TDS
- SC actrapid 0+TU
 Upon admission and review in ward
Date Progress I/O Plan
4/5/2022 Just admitted to ward 4A
no chest pain -cont under FM
No more SOB 5L/min
- ACS regimen for
on FM 5L/min
to complete 4
not tachypneic days
- T bisoprolol
O/E :Alert,conscious pink, 1.25mg OD
CRT<2s warm peripheries, - T perindopril 2mg
speak in phrases ,mildly OD
- T Atorvastatin
tachypneic 40mg OD
- SL GTN 1/1 PRN
BP 144/90 - IV lasix 40mg stat
HR 84 and TDS
RR 20 insulin regime:
Spo2 98 under FM5L - SC actrapid 0+TU
investigation
T 36.9 - ECG daily and
upon chest pain
GM 6.6 - ECHO inpatient cm

Lungs equal air entry, crepts

bibasally more on the left side
CVS DRNM
PA soft, non tender
no pedal edema
Date Progress Investigations I/O Plan

5/5/2022 Progress Hb 14. 0 -cont fmo2

- ACS regimen for
afebrile WCC 7.5
to complete 3
on s/c fondaparinux 2.5mg (d2) HCT 43.7
days
No episode of desaturation PLT 220 - T bisoprolol
overnight 1.25mg OD
no chest pain Urea 5.9 - T perindopril 2mg
no SOB Na 137 OD
on FM 5L/min K 3.6 - T Atorvastatin
40mg OD
not tachypneic Cr 93 - SL GTN 1/1 PRN
- IV lasix 40mg BD
o/e alert,conscious pink, ALP 57 insulin regime:
CRT<2s AST 37 - SC actrapid 0+TU
Good pulse volume warm ALT 22 - ECG daily and
peripheries not tachypneic TB 14.0 upon chest pain
- ECHO inpatient
DB 2.7
BP 135/57 IB 11.3
HR 69 TP 65
RR 22 Alb 37
Spo2 99 under FM5L Glo 29
T 36.9
ABG under
GM 5.8 FM5L
Ph 7.46
Lungs equal air entry, crepts Pco2 45
bibasally more on the left side Po2 69
CVS DRNM HCo3 32.0
PA soft, non tender BE 7.1
Lac 1. 0
mild pedal edema
Date Progress Investigations I/O Plan

6/5/2022 Progress 1050/1200

afebrile medications :
on s/c fondaparinux 2.5mg (d3)
(-150) - ACS regimen for
to complete 2
Saturating well under RA
days
no chest pain /SOB/palpitation - T bisoprolol
Tolerating orally well 1.25mg OD
No GI losses - T perindopril 2mg
weaned off o2 today OD
- T Atorvastatin
40mg OD
o/e alert,conscious pink, - SL GTN 1/1 PRN
CRT<2s - IV lasix 40mg BD
Good pulse volume warm - Started on T
peripheries not tachypneic empaglifozin
Speak in full phrase 12.5mg OD
- ECG daily and
upon chest pain
BP 129/60 - Aim discharge on
HR 60 Sunday if well
RR 18 completed ACS
Spo2 100 under RA treatment
T 36.9 - Memo to PPUM
upon discharge
- cardio referral IJN
GM 5.9 upon discharge

Lungs equal air entry, fairly

clear CVS DRNM
PA soft, non tender
JVP not raised

no pedal edema
Date Progress Investigations I/O Plan

7/5/2022 Progress 950/1250 medications

afebrile
on s/c fondaparinux 2.5mg (d4)
(-300) - ACS regimen for
to complete 1
Saturating under RA days
No episode of chest pain - T bisoprolol
no SOB 1.25mg OD
not tachypneic - T perindopril 2mg
Not tachycardic OD
- T Atorvastatin
40mg OD
o/e alert,conscious pink, - SL GTN 1/1 PRN
CRT<2s - oralised to t lasix
Good pulse volume warm 40 mg OD
peripheries not tachypneic insulin regime:
- SC actrapid 0+TU
- ECG daily and
BP 134/73 upon chest pain
HR 60 - cardio referral IJN
RR 18 upon discharge
Spo2 99 under FM5L TCA 1 June 2022 @
T 36.9 8am (OP 5176726)

GM 5.8

Lungs equal air entry,

CVS DRNM
PA soft, non tender
 Investigation at ward
• Echo was done on 5/5/22
 other investigations

1.Hba1c: 6.0%
2.FBS: 5.7 mmol/l
3.FSL
- TG: 1.5
- TC 5.9
- HDL 1.0
- LDL 3.2
• Patient was discharged on 8/5/22 after completed 5 days treatment of ACS
regimen
• Patient will continue his current treatment at IJN ( TCA @ 1 June 2022 )

Final impression :
1) Decompensated CCF secondary to NSTEMI (TIMI score 4) with type 1 respiratory
failure
- p/w failure symptoms ( orthopnea , SOB x2/12 )
- ECG in KPJ: sinus tachycardia, HR 110
- ECG x1: ST depression over V5 and V6, LVH, HR 98
- ECG x2: ST depression over V5 and V6, LVH, HR 103
- ECG x3: LVH, HR 95, no evolving changes
- CXR: overload picture, blunting bilateral costophrenic angle
- trop T (from KPJ): 0.045 (<0.014)
- RF: male, dyslipidemia, hypertension, hx of IHD
 take home message
1.ADHF is usually caused by several aetiologies,
ischemia can be one of the most common
cause.
2.Early management of ADHF mainly involves
use of diuretics to offload patient
3.Use of SGLT-2 in heart failure in patients with
reduced ejection fraction, improves CV risk
and mortality.