CHF NYHA III CHF NYHA III ec CADec CAD

ByByFinianty RayneldaFinianty Raynelda

Supervisor Supervisor

Prof. Dr. Peter Kabo, Sp.FK, PH.D, Prof. Dr. Peter Kabo, Sp.FK, PH.D, Sp.JP, FIHASp.JP, FIHA

Patient identityPatient identity NameName : Mr. : Mr. AA No.MRNo.MR : 3: 39362093620 AgeAge : : 6565 years old years old Gender Gender : Male: Male Date of admittance :0Date of admittance :01st1st Ju Julyly 2009 2009

History takingHistory takingChief complaint: Chief complaint: Shortness of breathShortness of breath

History taking: History taking:

Experienced Experienced 7 7 days ago, worsen 2 days ago, worsen 2 days before admitted to hospital. days before admitted to hospital. Precipitated by light exertion & lying Precipitated by light exertion & lying position, not by cold weather.position, not by cold weather.

Frequently waking up in the night Frequently waking up in the night gasping for breath, usually needs two gasping for breath, usually needs two pillows or more to sleeppillows or more to sleep

Crushing like chest pain (+) , intermitten Crushing like chest pain (+) , intermitten radiates to the left arm. radiates to the left arm. Cough(+), Cough(+), white sputum , fever(-), history of white sputum , fever(-), history of fever(-), nausea(fever(-), nausea(++), vomiting(), vomiting(++)) since since 2 day ago before enter the hospital2 day ago before enter the hospital,, epigastric pain(+)epigastric pain(+) descibed as sharp descibed as sharp and burning sensation at the middle and burning sensation at the middle of chest, and penetrate at the back.of chest, and penetrate at the back.

Defecation and urination is normalDefecation and urination is normal

Past Illness Past Illness HistoryHistory

History of heart disease (+).Patient had History of heart disease (+).Patient had been admitted to been admitted to Angkatan laut Hospital Angkatan laut Hospital for 2 day and diagnosedfor 2 day and diagnosed with Dyspepsiawith Dyspepsia

Family history of heart disease (-)Family history of heart disease (-)

Diabetes mellitus (Diabetes mellitus (--))

Family history of DM (Family history of DM (--) ) ..

History of History of Hypertension Hypertension since 5 years since 5 years agoago(-)(-). Patient did not control his . Patient did not control his medication regularlymedication regularly

Risk FactorRisk Factor Gender Gender : Male: Male AgeAge : : 6565 years old years old Ex-Smoker until Ex-Smoker until 1010 years previously. years previously. HHistory of istory of Hypertension for 5 yearsHypertension for 5 years

(+)(+)

Physical Physical ExaminationExamination

General Appearance : General Appearance : Severe-illness/normal weight/consciousSevere-illness/normal weight/conscious

Vital Sign :Vital Sign : Blood PressureBlood Pressure : 1: 1550/0/990 mmHg0 mmHg PulsePulse : 1: 11616 bpm, regular bpm, regular Respiratory rate Respiratory rate : 32 tpm: 32 tpm Body temperature Body temperature : 3: 36,76,7º C (axilla)º C (axilla)

Head Examination :Head Examination : Eyes : anemia(-), icterus(+), cyanosis(-)Eyes : anemia(-), icterus(+), cyanosis(-) Neck : JVP R+Neck : JVP R+11 cmH cmH2200

Thoracic Examination :Thoracic Examination : Inspection Inspection : Symmetric sinistra et dextra: Symmetric sinistra et dextra Palpation Palpation : No mass, no tenderness: No mass, no tenderness Percussion Percussion : Sonor: Sonor Auscultation : Breath Sound was bronchovesicular, rales Auscultation : Breath Sound was bronchovesicular, rales

+/+, wh -/-+/+, wh -/-

Physical Physical ExaminationExamination

Cardiac Examination :Cardiac Examination : InspectionInspection : Ictus Cordis wasn’t visible: Ictus Cordis wasn’t visible Palpation Palpation : Ictus Cordis wasn’t palpable: Ictus Cordis wasn’t palpable PercussionPercussion : : cardiomegalycardiomegaly

Upper borderUpper border : ICS II sinistra: ICS II sinistra Lower borderLower border : ICS V sinistra: ICS V sinistra Right borderRight border : right parasternalis line: right parasternalis line Left borderLeft border :: 3 finger from 3 finger from left medioclavicular line left medioclavicular line

Auscultation Auscultation : Regular of I/II Heart Sound, : Regular of I/II Heart Sound, no murmurno murmur

Abdominal Examination :Abdominal Examination :InspectionInspection : Normal: NormalPalpation Palpation : : No mass palpable, no

tenderness, the liver and spleen unpalpable.

Percussion Percussion : Tympani , Ascites (-): Tympani , Ascites (-)AuscultationAuscultation : peristaltic sound (+) , : peristaltic sound (+) ,

normalnormal

Extremities : Extremities : Oedema pretibial -/-Oedema pretibial -/-

Complete blood count Complete blood count WBC:11.73 x10WBC:11.73 x1033/ul/ul

RBC: 4.06x10RBC: 4.06x1066/ul/ulHGB: 13.0 gr/dlHGB: 13.0 gr/dlHCT: 39.0%HCT: 39.0%PLT: 126x10PLT: 126x1033/µl/µl

ElectrolyteElectrolyteSodium: 127 mmol/l (Sodium: 127 mmol/l (↓)↓)PotassiumPotassium : 4,6 mmol/l : 4,6 mmol/l Chloride: 103 mmol/lChloride: 103 mmol/l

Blood chemistry:Blood chemistry:GDS : 139 mg/dlGDS : 139 mg/dlUreum : 77 mg/dl (Ureum : 77 mg/dl (↑)↑)Creatinine : 0.9 mg/dlCreatinine : 0.9 mg/dlSGOT/SGPT: 700/666 u/dl SGOT/SGPT: 700/666 u/dl ((↑)↑)CK: 339 (>2N)CK: 339 (>2N)

CK-MB : 67 u/dl (>2N)CK-MB : 67 u/dl (>2N)

Sinus arhythmeSinus arhythme Heart rate 100 bpmHeart rate 100 bpm Axis : RADAxis : RAD P-mitralP-mitral cRBBBcRBBB Inferior wall sub acute miokard InfarctInferior wall sub acute miokard Infarct Whole anterior wall miokard ischemicWhole anterior wall miokard ischemic

LV DilatationLV Dilatation Global Hypokinetic, EF 18% Global Hypokinetic, EF 18% MI mildMI mild Doppler : E/A > 1Doppler : E/A > 1

Conclusion:Conclusion: LV DilatationLV Dilatation Global hypokinetic, EF 18%Global hypokinetic, EF 18% MI mildMI mild

Chest X-Ray - Bronchitis- Cardiomegaly with dilatatio et elongatio aortae- Atherosclerosis aortae

CHF NYHA III ec CADCHF NYHA III ec CAD

ManagementManagement Bed restBed rest Diabetic diet 1700 kklDiabetic diet 1700 kkl Cardiac DietCardiac Diet OO22 3-4 Lpm 3-4 Lpm IVFD NaCl 0.09% 10 dpmIVFD NaCl 0.09% 10 dpm Lasix 2 amp/12 hours/ivLasix 2 amp/12 hours/iv NTG NTG 110 0 μμg/g/kgBB/manusiakgBB/manusia Farsorbid 10 mg 3x1Farsorbid 10 mg 3x1 Captopril Captopril 6,256,25 mg 1-0-1 mg 1-0-1 Aspilet 80 mg 2x1Aspilet 80 mg 2x1 Clopidrogel 75 mg 1x4Clopidrogel 75 mg 1x4 Simvastatin 20 mg 0-01Simvastatin 20 mg 0-01 Alprazolam 0,5 mg 0-0-1Alprazolam 0,5 mg 0-0-1 Laxadyn syr 3x1 tsLaxadyn syr 3x1 ts

Coronary Heart DiseaseCoronary Heart Disease

Relating to disease processes that Relating to disease processes that affect the coronary arterial circulation affect the coronary arterial circulation with consequenses that affect the with consequenses that affect the coronary arterial circulation ,the coronary arterial circulation ,the heart and its function.heart and its function.

This term is generally restricted to This term is generally restricted to apply only to atherosclerotic coronary apply only to atherosclerotic coronary artery disease with the consequence artery disease with the consequence of ischemic heart disease.of ischemic heart disease.

Pathogenesis:Pathogenesis:

Myocardial O2 Myocardial O2 supplysupply

-Narrow vessel -Narrow vessel because plaque because plaque

- Forming of - Forming of trombus because trombus because

trombosite trombosite aggregationaggregation

- Spasme coronaria - Spasme coronaria

arteryartery

Myocardial O2 Myocardial O2 requirementsrequirements

- Activity increase - Activity increase

WHAT IS CHF ?WHAT IS CHF ? imbalance in pump function in which the imbalance in pump function in which the

heart fails to maintain the circulation of heart fails to maintain the circulation of blood adequately. blood adequately.

When CO became inadequate to fulfill the When CO became inadequate to fulfill the requirement of metabolism, heart would requirement of metabolism, heart would make mechanism of compensation.make mechanism of compensation.

But when the mechanism have been use But when the mechanism have been use maximally and CO still inadequate, then maximally and CO still inadequate, then symptoms of heart failure would be arise.symptoms of heart failure would be arise.

Contractility disturbance (eg. Contractility disturbance (eg. myocardial infarction; temporary myocardial infarction; temporary myocardial ischemia; chronic volume myocardial ischemia; chronic volume overload such as mitral & aortic overload such as mitral & aortic regurgitation).regurgitation).

Pressure overload (eg. aortic stenosis; Pressure overload (eg. aortic stenosis; uncontrolled hypertension)uncontrolled hypertension)

ArrhythmiasArrhythmias

NYHA Classification of Heart NYHA Classification of Heart FailureFailure

• II No symptoms and no limitation in ordinary physical No symptoms and no limitation in ordinary physical activity.activity.

• II II Mild symptoms and slight limitation during ordinary Mild symptoms and slight limitation during ordinary activity. activity. Comfortable at rest.Comfortable at rest.

• IIIIII Marked limitation in activity due to symptoms, even Marked limitation in activity due to symptoms, even during during less-than-ordinary activity. Comfortable only at rest.less-than-ordinary activity. Comfortable only at rest.

• IVIV Severe limitations. Experiences symptoms even while at Severe limitations. Experiences symptoms even while at rest.rest.

The Framingham criteria for CHF

CHF considered present if 2 major or 1 major & 2 minor

Prevention of initial cardiac injury: Coronary artery disease and hypertension are the two commonest causes of CHF. Dietary restrictions, exercise, weight reduction in obese individuals, cessation of smoking, and treatment of risk factors like a high cholesterol level and diabetes are important cornerstones in the prevention of CAD. Use of medications to control blood pressure also goes a long way in preventing CHF. Since heavy use of alcohol can contribute to the development of CHF, such a tendency needs to be discouraged.

Prevention of further injury: Aggressive early treatment of a heart attack reduces the amount of damaged muscle and decreases the likelihood and severity of CHF.

Prevention of post-injury deterioration: Studies have shown that patients who have suffered considerable muscle damage after a heart attack tend to do better if they are maintained on a class of drugs known as ACE inhibitors. It is believed that these medications prevent further deterioration.

General treatment of CHF.

How is CHF treated?How is CHF treated?

Managing afterload

Managing preload

Neurohumoral modulation

Managing contractility

-Cardiac glycosides-β – adrenergic-Phosphodiesterase inhibitors

-diuretic-venodilators

-Ca2+ channel blockers-Anti adrenergic -Vasodilators

-β blockers-ACE inhibitors-Angiotensin receptor blockers