Case Report :

CONGESTIVE HEART FAILURE NYHA III ec CORONARY ARTERY

DISEASE
Presented by:
Agni Khairani
Medita Aninditia Novianty
Fuji Febrianti
Aswin Yusuf
Supervisor
Dr. YULIUS PATIMANG, Sp.A, Sp.JP, FIHA
Department Of Cardiology And Vascular Medicine
Medical Faculty Of Hasanuddin University
Makassar
2016

Patient Identity
Name
: Mrs. S
Birth date/Age
: 01-07-1957 / 75 yo
Medical Record : 740995
Occupation
: Farmer
Marriage Status : Married
Admission Date
: 13/03/2016

History
Chief Complain : Shortness of Breathness
Guided Anamnesis :
A 75th years old, woman came with complaint shortness of
breathness about 1 weeks. Patient difficult to sleep since
the Shortness of Breath got worse with lying flat. The
patient sometimes wakes up during night caused by
sudden Short of Breath. The patient had cough before come
to hospital. There is no fever. Patient have history of
Diabetic Melitus Type II since 5 years ago and routine
control. History of chest pain (-), history of shortness of
breathness (-), and hypertension was deny.

History
Past History :
Diabetic Mellitus Type II since 5 years ago

Physical Examination

General Condition
Moderate Illness/Well Nourished / Compos Mentis (GCS 15)
Vital Sign

Blood pressure : 120/70mmHg

Heart rate

Respiratory rate

Temperature

: 80x/ min
: 20x/min
: 36,4 oC

Physical Examination
Head and Neck
Eye
Lip
Neck

: Conjunctiva anemic (-/-), Sclera icteric (-/-)

: Cyanosis (-)
: JVP R +3 cmHO

Thorax
Inspection : Symmetric between left and right chest.
Palpation : No mass, no tenderness.
Percussion : Sonor between left and right chest, lung-liver border n ICS IV
right anterior.
Auscultation: Respiratory sound: Vesicular
Additional sound :Ronchi mediobasal +/+, Wheezing +/+

Physical Examination

Cor :

Inspection

: ictus cordis not visible

Palpation

Percussion :
Upper border 2nd ICS sinistra
Right border 4th ICS linea parasternalis dextra
Left border 5th ICS linea axillaris anterior sinistra

Auscultation

: ictus cordis not palpable, thrill (-)

: heart sound I/II pure, regular, murmur (-)

Physical Examination

Abdomen
Inspection : Flat, follows breathing movement
Auscultation : Peristaltic sound (+), normal
Palpation : No mass, no tenderness, liver and spleen unpalpable
Percussion : Tympani (+)
Extremities examination
Pretibial

edema +/+

ECG

Pre Medication

Post Medication

ECG EXAM
Rhytm : Sinus Rhytm
Heart Rate: 80 tpm
Regularity : Regular
Aksis : Normo Axis
Interval P-R
: 0.24 s
QRS duration : 0.06 s
Gel P : Normal
Gel Q: Normal
Segmen ST : ST normal
Conclusion

: Sinus ritme, HR 80x/m, atrial extra sistol, normo axis, OMI

Anteroseptal

Laboratory
Test

Value

Unit

Normal Value

Routine Hematology
LBC
HCG
HBG

11,38
36,7
11,4

10^3/l
%
g/dL

4,00 10,00
37-48
12 -16

118
1,3

mg/dl
mg/dl

10-50
L(<1.3);P(<,1.1)

47
5,7
2,9
618

U/L
g/dL
g/dL
U/L

<38

12,3
62

Mg
mg/dL

P(2.4-5.7)
L(3.4-7.0)

96

Mmol/L

97-111

Blood Chemistry
Kidney Function
Urea
Creatinine
Liver Function
SGOT
Total Protein
Albumine
LDH

Other Chemistry
Uric Acid
Blood Lactate
Electrolyte
Chloride

Radiography : Chest Examination (PA)

INTERPRETATION :
Lung Edema Bilateral
Pleura Effusion
Bilateral

Resume
A 75 years old, woman came with chief complaint
dyspneu about 1 week. Orthopneu (+), Dyspneu on
Effort (+), and Paroxysmal Nocturnal Dyspneu (+). She
has cough before came to hospital. Dry cough. History
of short breathness was deny, history of hypertension
was deny. History of Diabetic Mellitus Type II (+) and
routine control.

Resume
ECG Exam:
Rhytm
: Sinus Rhytm
Heart Rate
80 tpm
Regularity : Regular
Aksis : Normo Axis
Interval P-R
: 0.24 s
QRS duration : 0.06 s
Gel P : Normal
Gel Q : Normal
Segmen ST
: ST normal
Conclusion

: Sinus ritme, HR 80x/m, atrial extra sistol, normo axis, OMI Anteroseptal

Laboratoty Exam:
Hipokalemi
Increase of transaminase enzim
Hiperuricemia

Radiology

Photo
Chest Exam P/A :

Lung Edema Bilateral

Pleura Effusion Bilateral

Diagnosis

CHF NYHA III ec CAD

CAD OMI Anteroseptal
DM TYPE II
Pleura Effusion Bilateral

Treatment
Oxygen 2-4 liters per minute via nasal
canula
IVFD Sodium Chloride 0,9% 500 cc/24
hours/IV
Furosemide 40 mg / 24 hours/ IV
Captopril 12,5 mg / 8 hours/ oral
Aspilet 80 mg / 24 hours / oral
Farsorbid 10 mg / 8 hours/ oral
Simvastatin 20 mg / 24 hours / oral
Micardis 20mg/24 hours/oral
Laxadine 10mg/24 hours /oral

Planning

1.
2.
3.
4.

Echocardiography
ECG Control
Electrolite test
Coronary Angiography

Discussion

Anatomy

DEFINITION
rt
a
e
H
ure
l
i
a
F

Heart failure is present when

the heart is unable to pump blood
forward
at a sufficient rate to meet the
metabolic
demands of the body (forward failure),
or
Is able to do so only if the cardiac filling
pressures are abnormally high
(backward failure),
or
both.

ETIOpatophysiology OF HEART FAILURE

Impaire
d
Diastoli
c Filling
Preserved ejection fraction
(Diastolic Dysfunction)

Impaired
Contractility

Hear
t
failur
e
Reduced ejection fraction
(Sistolic Dysfunction)

Afterload
(Chronic
Pressure
Overload)

clASSIFICATION OF CHF

DIAGNOSIS
ESC Guidelines for the diagnosis and treatment of
acute and
chronic heart failure 2008
Heart failure is clinical manifestation at the patient with
present of:
Characteristic of HF symptoms: shortness of breath at
rest or excersise, fatigue, pretibial edema.
AND
characteristic of HF sign: Tachycardia, tachypnea,
rales/ cracles, pleural effusion,rised of DVP, peripheral
edema, hepatomegaly.
AND
Objective sign that lead to structural or functional
heart dysfunction at rest.
cardiomegaly, S3, murmur (+), abnormality of ECG,
increased of natriuretic peptide consentration

The Framingham criteria for CHF

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

Major Criteria

Minor Criteria

Paroxysmal Nocturnal

Extremity edema

Dyspnea

Nocturnal cough

Cardiomegaly

Decreased vital

Gallop S3

pulmonary capacity

Hepatojugular reflux

(1/3 of maximal)

Increased of JVP

Hepatomegaly

Rales or ronchi

Pleural effusion

Acute pulmonary edema

Tachycardia (

Prolonged circulation

time(> 25 sec)

Weigh loss 4,5 kg in 5

days in

120bpm)

Dyspnea deffort

CHF MANAGEMENT
Identificatio
n and
correction
underlying
cause
Prolongatio
n of longterm
survival.

5 main
goals of
therapy

Modulation of
the
neurohormonal
to prevent
remodelling

. Elimination
of the acute
precipitating
cause
of
symptoms ,
e.g.
arrhythmia

Management
of heart
failure

CHF MANAGEMENT
Pharmacothera
py
Managing
preload

Managing
afterload

Managing
contractility

Neurohormonal
modulation
Diuretics

Venodilator

Inotropic agents :
digoxin
Cardiac glycosides
B- adrenergic
(dopamin,
dobutamin)

ACE
inhibitors
ARB
CCB

blockers
ACE
inhibitors
ARB