CASE REPORT OCTOBER 2015

Disusun Oleh:
Nur Arifah M. Said
C 111 10 841
Supervisor:
Prof. dr. Peter Kabo, PhD, SpFK, SpJP(K), FIHA, FAsCC
Department of Cardiology and Vascular Medicine
Medical Faculty of Hasanuddin University
Makassar
2015

PATIENT IDENTITY

Name
: Madam KS
Sex
: Female
Age
: 33 y.o.
Address
: Dusun Tanjung Sari
Status
: Married
Date Administrated : 03rd October 2015
MR
: 727972

HISTORY TAKING
Chief complaint : Shortness of breath(SOB)
History of present illness :
Suffered since 1 week before admitted. History of SOB
(+) since 3 years ago. SOB is described as feeling
heavy while breathing. SOB is felt while lying down(+)
and during activities(+) including minimal activities.
Patient have to sleep with more than 1 pillow(+). Patient
also woke up during the night because of tightness(+).
Another current complaint is the patient always feeling
palpitations since 3 years ago. The patient denied
having chest pain(-), fever(-), heartburn(-), nausea(-),
and vomit(-). Defecation and urination within normal
limits.

HISTORY TAKING
History of past/previous illness:
History of high blood pressure (-)
History of diabetes mellitus (-)
History of lung disease (-)
History of cyanosis at birth denied (-)
History of PND (+)
History of leg swelling (-)
History of smoking (-)
History of alcohol consumption (-)
Family with the same disease (-)
History of hospital admission(-)

PHYSICAL EXAMINATION

PHYSICAL EXAMINATION

PHYSICAL EXAMINATION

LABORATORY FINDINGS
RESULT

NORMAL

RESULT

NORMAL

WBC

9,35 [10^3/uL]

4.0-10.0

CKMB

13,7

<25

RBC

4,01 [10^6/uL]

4.00-5.00

GDS

126

80-180

HGB

11,4 [g/dL]

12.0-16.0

UREUM

16

10-50

HCT

35,3[%]

37.0-48.0

CREATININE

0,54

L(<1.3), P(<1,1)

PLT

177 [10^3/uL]

150-400

SGOT

19

<38

Na

143

136-145

SGPT

18

<41

3,7

3.5-5.1

PT

12,0

10 - 14

Cl

114

97-111

APTT

23,7

22,0 30,0

CK

35,00 [U/L]

L(<190), P(<167)

INR

1,15

ELECTROCARDIOGRAPH
o Sinus tachycardia, irregular.
o Heart rate: 121 bpm
o PR interval : difficult to assess
o P Wave: difficult to assess
o QRS rate: 0.12s
o ST segment: no elevation
o T wave: T inverted di lead II, III, aVF, V3, V4, V5, V6
Conclusion :
Atrial fibrillation
HR 110 bpm, normoaxis
Atrial fibrillation Rapid Ventricular Response

CHEST X-RAY
Conclusion:
Cardiomegaly
with signs of
pulmonary edema
Dilatation aortae

ECHOCARDIOGRAPH
Conclusion :
Ejection Fraction
59% (TEICH)
Systolic function
of LV is good
LVH excentric
MR moderate
TR mild, PH mild

RESUME

A woman 33 years old is admitted to the hospital with chief complaint shortness
of breath. The patient suffered shortness of breath since 1 week before admitted.
History of SOB (+) since 3 years ago. SOB is described as feeling heavy while
breathing. Orthopneau (+), DOE (+) and PND (+). Patient have to sleep with
more than 1 pillow (+). Patient also always feeling palpitations since 3 years
ago. From physical examination, the patients blood pressure is 100/70 mmHg,
heart rate is 137 beats/minute and respiratory rate is 26 x/minute. Besides that,
from head examination, the patients conjunctiva is anemic (+), and DVS R+3
cmH2O. From the auscultation of the lung, there is ronchi (+) at the basal of
lung. From the percussion of the heart, the left border of the heart is at 5th ICS
linea axillaris anterior sinistra and through auscultation examination, the heart
sound is irregular. Apart from that, there is slight edema (+) on both lower
extremities. From laboratory examination, the HGB is 11,4 [g/dL] and Chlorida
114. From electrocardiograph examination, the result is irregular, HR 121 bpm,
normoaxis, atrial fibrillation rapid ventricular response. In addition, the chest xray reveals that there is cardiomegaly with sign of pulmonary edema and
dilatation aortae. Last but not least, the result from echocardiography
examination is Systolic function of LV is good, with ejection fraction 59%, LVH
excentrik, MR moderate, TR mild and PH mild.

RISK FACTOR
Modified risk factor
Valvular Heart disease

Non-modified risk factor

Female

DIAGNOSIS
Congestive Heart Failure NYHA Class II ec Atrial Fibrillation
CHF:
- Major criteria: acute pulmonary edema, radiographic
cardiomegaly,
- Minor criteria: dyspnea on ordinary exertion, tachycardia
NYHA class III:
- Moderate limitation of physical activity, less than
ordinary activity leads to fatigue, palpitation, dyspnea or
anginal pain, asymptomatic at rest
Atrial Fibrillation:
- Symptoms: palpitation
- ECG: atrial fibrillation RvR

MANAGEMENT

Bed rest
Fluid restriction
Low salt diet
Oxygen 2-4 lpm/ nasal kanul
IVFD NaCl 0,9% 500cc/24 jam/intravena
Bolus digoxin 0,25 mg intravena
Amiodarone 600 mg/24 jam/syringe pump
Furosemide 40 mg/bolus intravena
Simarc 2 mg/24jam/oral

DISCUSSION
Congestive Heart
Failure (CHF)

DEFINITION OF CHF

Etiology of
Heart Failure

Main Causes
Ischemic heart
disease (35%-40%)
Cardiomyopathy(dilated)
(30-40%)

Hypertension ( 15-20%)

Other Causes
Arrhythmias
Valvular heart disease
Congenital heart disease
Pericardial disease
Hyperdynamic circulation
Alcohol and
drugs(chemotherapy)

Major Criteria

Minor Criteria

Paroxysmal Nocturnal Dyspnea

Extremity edema

Cardiomegaly

Nocturnal cough

Gallop S3

Decreased vital pulmonary

Hepatojugular reflux

capacity (1/3 of maximal)

Increased of JVP

Hepatomegaly

Rales or ronchi

Pleural effusion

Acute pulmonary edema

Tachycardia ( 120bpm)

Prolonged circulation time(> 25

Dyspnea deffort

sec)
Weigh loss 4,5 kg in 5 days in
response to treatment of CHF

Classification of CHF

Pathophysiology of CHF

MANAGEMENT of CHF

NonPharmacology

MANAGEMENT of CHF
Pharmacology

ATRIAL
FIBRILLATION (AF)

DEFINITION of AF
An irregular and often rapid heart rate
Commonly causes poor blood flow to the
body.
The heart's two upper chambers
(the atria) beat chaotically and irregularly
out of coordination with the two lower
chambers (the ventricles) of the heart.

ETIOLOGY of AF
Cardiac causes of AF
Common cardiac causes :
- Ischemic heart disease
- Rheumatic Heart Disease
- Hypertension
Less common cardiac causes :
- Cardiomyopathy or heart
muscle disease
- pericardial disease
- Atrial septal defect

Non-cardiac causes of AF
- Acute infection especially
pneumonia
- Electrolyte depletion
- Lung carcinoma
- Pulmonary embolism
- Thyrotoxicosis

RISK FACTOR of AF

CLASSIFICATION of AF
INITIAL/FIRST
EVENT

- AF in younger patients without structural heart disease

- It generally refers to paroxysmal, persistent, or permanent
AF in younger patients (< 60 y) who have normal
echocardiographic findings

PAROXYSMAL

- Episodes terminate spontaneously within 7 days (most

episodes last <24 hours)

PERSISTENT

- Episodes last >7 days

- May require either pharmacologic or electrical intervention to
terminate

PERMANENT

- AF that has persisted for >1 year, either because

cardioversion has failed or because cardioversion has
not been attempted

CLASSIFICATION of AF
Based on the presence or absence of underlying disease :
Primary AF not accompanied by heart disease or
other systemic diseases
Secondary AF accompanied by heart disease or
systemic diseases such as thyroid disorders
Based on ventricle response towards fibrillation rhythm :
FA with normal ventricular response : ventricular rate
60-100x/min
FA with rapid ventricular response : ventricular rate
>100x/min
FA with slow ventricular response : ventricular rate
<60x/min

CLASSIFICATION of AF
Based on EHRA score :

PATHOPHYSIOLOGY of AF

Circuit Reentry

Condition :
Unidirectional block
Slow conduction

In normal conditions the impulse that

passing through multipe track (1) and
(2) will neutralize each other (3). If
there is an unidirectional block, the
impulse cannot pass through the
track (2) from anterograde direction
but could pass through the track (2)
from retrograde direction at a lower
speed, as a result track (1) has
completed repolarization until the
impulse from the track (2) can be
pass through the track (1). Then,
reentry circuits happened.

HOW TO DIAGNOSE AF
Sign and Symptom :

HOW TO DIAGNOSE AF
Physical Examination :
Vital signs
Irregular pulse and tachycardic (HR: 110-140)
Head and neck
Examination of the head and neck may reveal
exophthalmos, thyromegaly, elevated jugular venous
pressures, or cyanosis.
Pulmonary
Evidence of heart failure (eg, rales, pleural effusion).
Wheezes or diminished breath sounds are suggestive
of underlying pulmonary disease (eg, COPD, asthma).

HOW TO DIAGNOSE AF
Physical Examination :
Cardiac
Thorough palpation and auscultation evaluate for valvular
heart disease or cardiomyopathy.
A displaced point of maximal impulse or S 3 suggests
ventricular enlargement and elevated left ventricular pressure.
A prominent P2 points to the presence of pulmonary
hypertension.
Abdomen
The presence of ascites, hepatomegaly, or hepatic capsular
tenderness suggests right ventricular failure or intrinsic liver
disease.
Left upper quadrant pain may suggest splenic infarct from
peripheral embolization.

HOW TO DIAGNOSE AF
Physical Examination :
Lower extremities
Examination of the lower extremities may reveal
cyanosis, clubbing, or edema.
A cool or cold pulseless extremity may suggest
peripheral embolization
Neurologic
Signs of a transient ischemic attack or
cerebrovascular accident may be discovered.
Evidence of prior stroke and increased reflexes is
suggestive of hyperthyroidism.

HOW TO DIAGNOSE AF
Laboratorium
CBC count
Serum electrolytes and
BUN/creatine (electrolyte
disturbances or renal failure)
Cardiac enzymes CK or
troponin level ( to investigate
Myocardial infarction)
BNP (evaluate CHF)
D-dimer (pulmonary
embolism)
Thyroid function (looking for
thyrotoxicosis)

Chest Radiography
Usually normal
However, chest
radiography may provide
evidence of CHF as well
as signs of lung or
vascular pathology (eg,
pulmonary embolism,
pneumonia).

HOW TO DIAGNOSE AF
Electrocardiography:
Irregularly irregular rhythm
Heart rate tachycardia
No P waves
Absence of an isoelectric baseline
Variable ventricular rate
QRS complexes usually <120ms unless
pre-existing bundle branch block, accessory
pathway, or rate related aberrant conduction

MANAGEMENT OF AF
Heart Rate Control
The main target of this approach is to relieve the clinical
symptoms and the prevention of hemodynamic
complications by controlling the rate of ventricular
response. Targeted therapy ventricle rate between 6080 bpm at rest and during exertion activity is 90-115
bpm. Drugs that may be given -blockers, calcium
channel blockers non dihydropiridin and digoxin.
Rhythm Control

Anti-thrombolytic

MANAGEMENT OF AF

MANAGEMENT OF AF

PREVENTION OF
THROMBOEMBOLISM
CHA2DS2VAS score
The cumulative
scoring system that
predicts the risk of
stroke in patients
with atrial fibrillation
A higher CHADS
score accordance
with a greater risk of
stroke , while low
scores of CHADS
accordance with a
lower risk of stroke.

PREVENTION OF
THROMBOEMBOLISM

PROGNOSIS OF AF
Treatment can often control this disorder.
Many people with atrial fibrillation do very
well.
Atrial fibrillation tends to return and get
worse. It may come back even with
treatment.
Clots that break off and travel to the brain
can cause a stroke.