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 to hospital : August 21st, 2015

History Taking
Chief complain: Shortness of breath
Suffered since 4 years ago, get worse 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(+), 1 year ago
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 (underweight)

Vital signs:
BP: 140/90 mmHg
HR: 80 bpm
RR: 26 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
Interpretation
Basic rhytm: sinus
Heart rate : 79 bpm
Regularity : regular
Axis
: normoaxis
Morphology
P Wave
: 0,08 second,
biphasic on V1
PR interval : 0,20 second
Kompleks QRS : 0,08 second,
R wave on I, II, III,aVF, V6; QS
on V1-2; Rs on V3-V5
ST segment: depression on
V5-V6, I, aVL
T wave
: inverted on V3V4
Conclusion : Sinus Rhytm,
HR 79bpm, normoaxis,
Non-ST elevation myocard
infarct anterolateral

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 4 lpm via nasal canul

IVFD NaCl 0,9% 500 cc/24 hours/IV
Furosemide 40 mg/8 jam/intravena
Aspilet 80 mg/24 hour/ oral
Clopidogrel 75 mg/24 hours /oral
Isosorbid dinitrate 1mg/hour/syringe pump
Isosorbid dinitrate 5mg/sublingual if pain
Fondaparinuks 2,5mg/24 hours/subcutan

DISCUSSION
1. Congestive Heart Failure
2. NSTEMI

CONGESTIVE HEART FAILURE

Definition
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 if only the
cardiac filling pressure are abnormally high (backward
failure), or both.

CONGESTIVE HEART FAILURE

Physiology

CONGESTIVE HEART FAILURE

Physiology

CONGESTIVE HEART FAILURE

Pathophysiology

CONGESTIVE HEART FAILURE

Pathophysiology

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;

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

CONGESTIVE HEART FAILURE

Treatment of HF w/ Reduce EF
1.Diuretics
Elimination of
sodium and water
through the kidney

intravascular
vol.
venous return
preload the LV

CONGESTIVE HEART FAILURE

Treatment of HF w/ Reduce EF
2. Vasodilators
- Venous vasodilators (eg nitrates) :
venous capacitance venous return
LV diastolic pressure & pulmonary capillary
hydostatic pressure
- Pure arteriolar vasodilators (eg hydralazine) :
systemic vasc resistance & LV afterload
ventricular muscle fiber shortening during
systole stroke volume
- Vasodilator both the venous & arteriolar :
ACE-I & ARB

CONGESTIVE HEART FAILURE

Treatment of HF w/ Reduce EF
ACE-I & ARB

CONGESTIVE HEART FAILURE

Treatment of HF w/ Reduce EF
3. Inotropic drugs
- -adrenergic agonists (eg dobutamine and
dopamine)
- Digitalis glycosides (digoxin)
4. -blocker
bisoprolol, metoprolol, and carvedilol

CONGESTIVE HEART FAILURE

Treatment of HF w/ Preserved EF
The goals of therapy :
1. The relief of pulmonary and
congestion
2. Addressing correctable causes
impaired diastolic function

systemic
of

the

NSTEMI

Definition
Case
History Taking:
- Chest paint
- Blunt
- Suddenly
- Provoked by activity (-)
- Cold sweat
ECG:
- ST-segment depression
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