Cardiovascular Department

Faculty of Medicine
Universitas Hasanuddin

Case Report
September, 2015

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

Patients Identity

Name : Mr. SD
Age
: 77 years old
MR
: 723072
Address : Mamasa
Admitted : August 21st, 2015

History Taking

Chief complain: Breathless

Suffered since 4 years, worsen 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 (-)

History Taking
Hypertension (+) since 10 years ago (consumes
anti-hypertension irregularly)
Diabetic mellitus(-)
Previous heart disease(+)
Family history of heart disease (-)
Smoking (+), alcoholic (-)

Risk Factors
Modifiable:
Smoking,
Hypertension

Non modifiable:
Age (77 y.o)
Gender (male)

Physical Examination
General state:
moderate illness, poor-nourished, compos mentis

BMI: 18,35 kg/m2 (overweight)

Vital signs:
BP: 120/90 mmHg
HR: 72 bpm
RR: 22 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

Extremities :
Edema (-)

: tympani

ECG

Laboratory
Findings
Laboratory
Finding
August 21st, 2015

Radiology
Findings Findings
Radiology
Chest X-Ray
(August 22nd, 2015)
Cardiomegaly with dilatatio
et elongatio aortae

Radiology Findings
Abdominal USG
(August 25th, 2015)
Prostate
hypertrophy
Right kidney cyst

Echocardiography
-Left ventricle systolic and
diastolic disfunction
-Segmental hypokinetic
-Concentric left ventricle
hypertrophy
-Mild aortic regurgitation

Assessments
Congestive Heart Failure NYHA III Post Acute Lung
Oedema
Non-ST-Segment Elevation Myocardial Infarction

Management
1.
2.
3.
4.
5.
6.
7.
8.

Oxygen 6 lpm via simple mask

IVFD NaCl 0,9% 500 cc/24 hours/IV
Furosemide 200 mg/24 hours /syringe pump
Aspilet 80 mg/24 hours oral
Clopidogrel 75 mg/24 hours /oral
Cedocard 1mg/hour/syringe pump
Isosorbid dinitrate 5mg/sublingual if pain
Arixtra 2,5mg/24 hours/subcutan

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 H 20;
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