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Congestive Heart Failure

Ivan Virnanda Amu

Pendrik Tandean


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I N T R O D U C T I O N(1)

Clinical manifestations ofheart failure consists ofvarious hemodynamic

response, renal, neural, andhormonal abnormalities.

Heart failure is the inability of the heart to maintain cardiac

output to support metabolic demands of the body.The decrease in cardiac output resulting in reduced effective

blood volume.

Reflex of homeostasis/compensation

mechanism :

Neurohormonal changes

Ventricular dilatation

Frank-Starling mechanism.


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Anamnesis

Date Here

Mr. M, Men, 61 y.o, admitted to ER (Januari 22nd, 2014) with chief complain

shothness of breath, since 1 week ago and worsening 1 day ago, intermittent,

DOE (+), PND (+). patients feel claustrophobic if the move where previously

activity is never compromised patients, patients slept with 2 pillows. During

the last month patient feel tired easily, always feel weak, and spent a longer

time to rest so that productivity decreases.

Occasionally cough, dry cough, no fever, there is no history of fever.

No chest pain, there is history of chest pain approximately 4 months ago, with pressed-

like sensation on centre of chest, radiated to left arm, with cold sweating, It felt more

than 1-2 minutes.


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Anamnesis (2)

Micturation and defecation normal, as usual.

There is history of Coronary Disease since 4 months ago,

but the patient did not take a medicine and go to the

doctor.

History of Hypertension since 3 years ago, but the patients

didnt take medicine regularly

History of Smoking, one pack daily.

History of DM (-)


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Physical Examination (1)

General Status Moderate ill/Well nourish/conscious.

Vital status : BP 140/80 mmHg, pulse 105 beats / min, regular, RR 28 /

min, temperature 36.7 C axiller, Weight 50 kg, Height 163 cm,BMI21.67

Head and Neck

Anemia (-), Icteric (-), cyanosis (-). No lymph nodes enlargement. Nodeviation of the trachea and Jugular Venous Pressure R +3 cmH20

Thorax

Lung

Inspection : looks symmetrical, does not seem respiratory lag,

Palpation : No tumor mass, between the ribs is not widened, tactile

fremitus normal, resonant percussion. Vesicular breath sounds onauscultation, Rales : both of lung bases.

Cardiac

Inspection ictus cordis does not appear and was not palpable, NormalImpression of heart border, Heart Sound I / II regular, Murmur (-)


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Physical Examination(2)

Abdominal

Insp : Ascites -/-

Palp : Liver and spleen : No enlargement.

Perc : Tympani.

Ausc : Peristaltic Normal.

Extremity

Edema -/-

Warm acral


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Laboratory ExamWBC 7,5 103/mm3

Eritrosit 5.15 106/mm3

Hb 16,0 g/dl

HCT 46,6 %

MCV 97 m3

MCH 31,1 pg

MCHC 32,2 g/dl

RDW 15,2 %

PLT 182 103/mm3

MPV 7,7 m3

NEU 61,4 %

LYM 26,4 %

MON 5,7 %

EOS 3,3 %

BAS 3,2 %

Total Cholesterol 167 mg/dl

LDL 27 mg/dl

HDL 140 mg/dl

TG 85 mg/dl

CK 121 U/L

CKMB 16 U/L

Troponin T < 0,002

Uric Acid 9,4 mg/dl

HbsAg ReaktifPT 12,7 control 10,0

INR 1,09

aPTT 34,9 control 23,7

GDS 112 mg/dl

Ureum 40 mg/dl

Creatinine 1,3 mg/dl

SGOT 21 U/L

SGPT 18 U/L

Natrium 145 mmol/l

Kalium 3,6 mmol/l

Chlorida 115 mmol/l


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ECG

Sinus Rhytm, HR 103x/m, Axis +170 , P wave 0,08 s, QRS complex 0,08 s, PR Interval 0,16 s, QS Configuration V1-V4,

Conclussion : Sinus Tachycardia, RAD, OMI Anteroseptal


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Chest Radiology

Dilatation of hillus,parahillar, and suprahillarboth of lung

No spesific both of lung

Cor : CTI 0,57 aorta

dilatation Normal Sinus and

diaphragm

Intact bone

Conclussion :Cardiomegaly withpulmonary congestion.

Aorta dilatation


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Echocardiography

Conclussion :

Sistolic and Diastolicdysfunction LV, EF 29 %

Dilatation of LA and LV Anterior akinetic

anterior, anteroseptal.Hipokinetic in the othersegment

MR severe

AR trivial


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Working Diagnosis

CHF Nyha III ec CAD

Hyperuricemia

HBV


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Oxygen 2-3 Lpm via nasal canula

NaCl 0,9 % 500 cc/24 hours/IV

Lasix 40 mg/12 hours/IV

Aspillet 1x 80 mg

ISDN 3 x 10 mg

Captoril 2x12,5 mg

Simvastatin 1x20 mg

Allopurinol 1x300 mg

M

A

N

A

GE

M

E

NT


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DISCUSSION

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Systolic heart failure is the

inability of the heart to pump

so that the contraction of the

heart decreases and

weakness, fatigue, and

decreased physical activity

abilities and other symptoms

of hypoperfusion.

Diastolic heart failure is a

disorder of impaired relaxation

and ventricular filling. Diastolic

heart failure is defined as heart

failure with an ejection fractionof more than 50 %.


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Myocardial disease

Coronary heart disease (ischemic heart

disease)

Cardiomyopathy

Myocarditis and rheumatic heartdisease

Infiltrative disease

Iatrogenic due to drugs or as a result of

radiation

Mechanical disturbance in myocardialinfarction alone so there is actually no

abnormalities.

Pressure overload, such as

hypertension, aortic stenosis, aortic

coartasio.

Volume Overloaded, such as aortic ormitral insufficiency, congenital heart

disease (left to right shunt) or

excessive transfusion.

Barriers charging, such as constrictive

pericarditis or tamponade.

TIOLOGY


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PATHOPHYSIOLOGY


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Pulmonary symptoms include: dyspnoea,

paroxysmal nocturnal dyspnea and orthopneu.

Additionally nonproductive cough that arise at

the time of lay

SIGN AND

SYMPTOMS

Systemic signs and symptoms such as weakness,

rapid fatigue, oliguria, nausea, vomiting, increased

central venous insistence, tachycardia, narrow

pulse pressure, ascites, hepatomegaly, and

peripheral edema

Nervous system symptoms such as : insomnia,

headaches, nightmares until delirium


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FRAMINGHAMS CRITERIA

MAJOR K MINOR

Extremity edema

Nocturnal cough

Dyspnea d' effort

Hepatomegaly

Pleural effusion

Decrease in vital capacity 1/3 of the normal Tachycardia ( > 120 beats / min)

Major or minorWeight loss 4.5 kg in 5 days of

treatment. Diagnosis of heart failure confirmed at

least 1 major criteria and 2 minor criteria

Paroxysmal nocturnal dyspnea

Neck vein distention

Pulmonary Crackles

Cardiomegaly

Acute pulmonary edema S3 Gallop

Elevation of jugular venous

Hepatojuguler Reflex


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ACUTE CHF

Sign :

Typical symptoms of pulmonary edema : dyspnea,

orthopnea, tachypnea, cough with frothy sputum,

sometimes hemoptysis.

Output of symptoms : tachycardia, hypotension and

oliguria

Angina pectoris on myocardial infarction .

Impaired left ventricular function are severe , it can be

found pulsus alternans.

Cardiogenic shock

Third heart sound (diastolic gallop).

Murmur sound in case of ventricular

dilatation.

Crackles wet

Lab findingincrease RBC

decrease in PO2

Acidosis on blood gas analysis

ECG :

tachycardia ( except those already treated ).

ischemic

impaired ventricular conduction function,

left bundle - branch block ( LBBB ),

changes in the ST segment and T wave

Chest X-Ray

Cardiomegaly, signs of lung dam

Pleural Effusion


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A

B

C

Patients at risk of suffering from heart failure but no signs of heart failure, for

example patients with CHD, diabetes, cardiomyopathy and hypertension.

Patients suffering from Structural Heart Disease and

symptoms of heart failure

D Refractory heart failure despite maximal therapy. In this groupit is necessary for specific intervention such as a heart

transplant, permanent mechanical support.

Patients suffering from structural heart disease. But there is no sign

of heart failure eg myocardial infarction, LVH or valvular heart

disease

American College of Cardiology / American HeartAssociation 2005 Guidelines Update (4 levels severity)


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MANAGEMENT

Increasing the

cardiac output

Decrease

ventricular fillingpressure

Overcome heart failure

syndrome

ACUTE

CHF


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MANAGEMENT CHRONIC CHF

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4. Prevent myocardial remodeling and inhibit theprogression of heart failure (ACE Inhibitor, ARB)

5. Fixing myocardial energy metabolism withcarnitine, Co - enzyme Q10, D - ribose, magnesium

and vitamins.

6. Nonpharmacologic interventions aimed specifically for stage D of heart

failure patients who have not responded to medication. The specific

interventions can be Implantable Defibrillators Caardioverter (ICD),

Boventricular Pacing Theraphy, revascularization by PTCA or CABG 's, heart

transplantation, and ventricular reduction cardioplasti .


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HEART FAILURE with Normal Systolic

Function

Increased in parallel with age

Mainly found in women

Symptoms : decrease in exercise capacity,

neurohormonal activation and decreasedquality of life.

Specific treatment against heart failure with

normal systolic function does not exist. D-ribose, L-carnitine and Co-enzyme Q10

reported to improve output


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