HEART FAILURE

CASE PRESENTATION BY SENIOR INTERNS

CHAPTER I INTRODUCTON
CHAPTER II LITERATURE STUDIES

DEFINITION
EPIDEMIOLOGY
ETIOLOGY
PATHOPHYSIOLOGY
SIGN AND SYMPTOM
WORKUP
MANAGEMENT AND TREATMENT

CHAPTER III CASE REPORT

CHAPTER IV DISCUSSION
CHAPTER V CONCLUSION

introduction
1

Chapter

PERKI
(2015)
Maryono
and Santoso
(2007)

progressive health
problems, high mortality
and morbidity
The incidence will increase
in the future,
the therapeutic treatment
improves the survival rate
with decreased heart
function
Heart failure is difficult to
be detected clinically,
only few clinical signs in the
early stages known,

Literature
study
2
Chapter

DEFINITIO
N

Heart (or cardiac) failure is

a clinical syndrome which its
symptoms and signs caused
by structural and/or functional
cardiac abnormalities,
resulting reduced CO or
elevated intracardiac pressure
at rest/stress.
(2016 ESC Guideline for the
Diagnosis and Treatment of Acute
and Chronic Heart Failure)

HF is a complex clinical
syndrome that results from
any structural and/or
functional impairment of
ventricular filling or ejection
of blood.
(2013 ACCF/AHA Guideline for
the Management of Heart
Failure)

Epidemiolog
y

Five hospitals in Java and Bali island 1687 patients with ADHF were
admitted at the emergency room
Mean age was 60 years, 64.5% male.
Compared to other countries (Asia Pasific, Europe, US), Indonesian
patients were sicker, had more severe symptoms, lower ejection
fraction, as well as higher in-hospital mortality (6.7%).
(ADHERE, 2006)

Etiology
Systolic failure- most common cause
Hallmark finding: Decreased *left ventricular
ejection fraction (EF)
Due to

Impaired contractile function (e.g., MI)

Increased afterload (e.g., hypertension)
Cardiomyopathy
Mechanical abnormalities (e.g., valve
disease)

Etiology
Diastolic failure
Impaired ability of ventricles to relax and fill
during diastole decreased stroke volume and
CO
Diagnosis based on presence of pulmonary
congestion, pulmonary hypertension,
ventricular hypertrophy
*normal ejection fraction (EF)

Etiology
Mixed systolic and diastolic failure
Seen in disease states such as dilated
cardiomyopathy (DCM)
Poor EFs (<35%)
High pulmonary pressures
Biventricular failure (both ventricles may be
dilated and have poor filling and emptying
capacity)

Risk Factors for Heart Failure

Coronary artery
disease
Hypertension
(LVH)
Valvular heart
disease
Alcoholism
Infection (viral)

Diabetes
Congenital heart
defects
Other:
Obesity
Age
Smoking
High or low
hematocrit level
Obstructive Sleep
Apnea

Pathologic Progression of CV Disease

Sudden
Death

Coronary
artery disease
Hypertension
Diabetes

Myocardial
injury

Pathologic
remodeling

Low ejection
fraction

Cardiomyopat
hy
Valvular
disease

Death

Pum
p
failur
e

Neurohormon
al
stimulation
Myocardial
toxicity
Adapted from Cohn JN. N Engl J Med. 1996;335:490498.

Symptoms:
Dyspnea
Fatigue
Edema

Chronic
heart
failure

Compensatory Mechanisms:
Renin-Angiotensin-Aldosterone System
Beta
Stimulation
CO
Na+

Renin + Angiotensinogen
Angiotensin I
ACE
Angiotensin II

Peripheral
Vasoconstrictio
n

Kaliuresis

Aldosterone Secretion

Fibrosis

Salt & Water Retention

Plasma Volume

Afterload
Cardiac Output

Heart Failure

Preload
Cardiac Workload

Edema

Signs and symptoms

Framingham Criteria for
Congestive Heart Failure
Requires the
simultaneous presence
of at least

2 major criteria or 1
major criterion in
conjunction with 2
minor criteria
100% sensitive and
78% specific for
identifying person with
definite congestive

Signs and symptoms

Framingham Criteria for
Congestive Heart Failure
Major symptoms
Minor symptoms

Paroxysmal nocturnal dyspnea

Jugular vein distention
Rales
Radiographic cardiomegaly
(increasing heart size on chest
radiography)
Acute pulmonary edema
S3 gallop
Increased central venous pressure
(>16 cm H2O at right atrium)
Hepatojugular reflux
Weight loss >4.5 kg in 5 days in
response to treatment

Bilateral ankle edema

Nocturnal cough
Dyspnea on ordinary exertion
Hepatomegaly
Pleural effusion
Decreased vital capacity by
one third from maximum
recorded
Tachycardia (heart rate >120
beats/min.)

Signs and symptoms

Shortness of breath often with
activities or while lying flat
Weakness and fatigue
Awakening short of breath at
night
Need for increased pillows at
night helps lungs drain of
excess fluid
Coughing or wheezing
Swelling of feet and legs or
other dependent areas
Anorexia/loss of appetite
Weight gain

Symptoms
Fatigue
Activity decrease
Cough (especially
supine)
Edema
Shortness of breath

A Key Indicator for Diagnosing Heart Failure

Ejection
Fraction
(EF)
Ejection Fraction
(EF) is the
percentage of
blood that is
pumped out of
your heart during
each beat

How Heart Failure Is Diagnosed

Medical
history

Physica
l
Examin
ation

Tests
Chest X-ray
Blood tests
ECG
Echocardiograp
hy
Angiogram

Treatment of Heart Failure

PATIENT STATUS

Identity

Name
: Tn. S
Regist
: 01282216
Age
: 55
Gender
: Male
Address
: Giriwoyo, Wonogiri
Date of admission
: May 29th 2016

ANAMNESIS

: dyspnoea
CHIEF COMPLAINT

HISTORY OF PRESENTING
ILLNESSES
Patient complained of dyspnoea since 2

weeks before being admitted into hospital,

worsening since 2 days. Worsen by activity,
relieved by rest.
Paroxysmal nocturnal dyspnoea
Usually sleeping with 4 pillow.
No complain with defecation and micturition

Past Medical History

Congestive Heart Failure for past 2 years

Under follow-up at Dr. Moewardi Hospital for 2 years
and Batu Retno Hospital for 4 months.
Diabetes Mellitus (-)
Hypertension (-)

Medical Family History

Cardiovascular disease (+)

Hypertension (+)
Diabetes Mellitus (-)

Past Medication History

Digoxin 1 x 0,25 mg

Diovan 1 x 80 mg
Furosemide 1 x 40 mg

Spironolactone 1 x 20 mg

Lansoprazole 1 x 30 mg

Ulsafate 3 x 500 mg

KSR 1 x 1

PHYSICAL EXAMINATION

Vital Sign
Blood Pressure : 120/80 mmHg
Pulse Rate
: 88 pulses/minute
Heart Rate
: 88 pulses/minute
Respiration Rate : 22 breaths/minute
Temperature
: 37C

Physical Examination
Cor
I : IC seen
P : IC palpable
P : Widened cardiac left border
A : S (I-II) N, reguler, pansystolic
murmur (+) III/6 apex
Pulmo : vesiculer +/+,
rales +/+ minimal
Ext :
Cyanosis - - Bilateral ankle oedem

anemic conjunctival -/icteric scleral -/-

JVP distended

Abdomen:
flat, hepar/lien
palpable

WORKUP

ECG

Thorax Rontgen

Cardiomegaly with
aortosclerosis

Pulmonary oedema with

bilateral pleural effusion

Echocardiography

Dilated all chamber (EF = 31%)

MR, TR and PR mild

Laboratory
Parameter

Result

Normal Range

Hemoglobin

17.7

13.5-17.5 g/dl

Hematocrit

52

33-45 %

Leukocyte

13.5

4.5 11.0 ribu/ul

Thrombocyte

285

150 450 ribu/ul

Erythrocyte

6.01

4.50 5.90 juta/ul

Glucose

88

60 - 140 mg/dl

SGOT

91

<35 u/l

SGPT

62

<45 u/l

Hematology

Chemical Clinic

Laboratory
Parameter

Result

Normal Range

Albumin

3.8

3.5 5.2 g/dl

Creatinine

1.6

0.9 1.3 mg/dl

Ureum

83

0.9 1.3 mg/dl

Sodium

131

136 145 mmol/L

Potassium

5.2

3.3 5.1 mmol/L

Chloride

94

98 106 mmol/L

Electrolyte

Laboratory
Blood Gas Analysis
PH

7.410

7.350 7.450

BE

-9.4

-2 - +3 mmol/L

PCO2

24.0

27.0 41.0 mmHg

PO2

141.0

83.0 108.0 mmHg

Hematocrit

56

37 50 %

HCO3

19.5

21.0 28.0 mmol/L

Total CO2

15.9

19.0 24.0 mmol/L

O2
Saturation

99.0

94.0 98.0 %

ASSESMENT

Ax : Old Myocard Infarct

anterior
Fx : Acute Decompensated
Heart Failure
Ax : Coronary heart disease
M : - Dyspepsia
- Increased enzyme
transaminase
- Leukocytosis
- Azotemia

PLANNING

P. Th/

P. Dx/

Total bed rest

ECG/day

O2 3 lpm
Diet 1700 kkal

Complete laboratory
exam

Inf RL 30 cc/hour

Fluid balance monitoring

Furosemide inj 20mg/8

hour

Aspilet 1x 8 mg
Simvastatin 1 x 20 mg

Ranitidine inj 50 mg/12

hour

Spironolactone 1 x 25 mg

Captopril 3 x 12,5 mg

Chapter

DISCUSSION

Coronary
artery
disease

Hypertensio
n

Sympathetic
activation
Decreased
parasympathetic
activity
Baroreceptor
dysfunction

Structural
and/or
function
cardiac
abnormality

Neurohormonal
changes

RAAS
system
activation
Releasing
ANP and BNP
Increased
vasopressin and
endothelin
Other effect by
PGE, bradykinin,
NO

Vascular
tone
Electrolytes
balance
Hemodynamic
effects

Myocard
contractility
Heart rate
Cardiac
output

ESC Guidelines for the diagnosis and treatment of acute and chronic heart
failure, 2016

In this case, patient had:

1. History of myocard infarction
2. High blood pressure (150/100 mmHg)
3. Orthopnoea, PND, dyspnoea on effort
4. Low EF (31%)
5. Structural cardiac abnormality (chambers and valve)
6. Minimal rales
7. Bilateral ankle oedema
8. Pansystolic murmur
9. Widened cardiac left border
10.Accelerated junctional rhythm, LAD, ST elevation in I, aVL,
V2-V5, Q wave on ECG

Clinical reason in using medication:

1. Captopril inhibits ACE in RAAS system
2. Aspilet prevents new thrombus formation
3. Furosemide increases sodium and water excretion
oedema
4. Spironolactone prevents hypokalaemia and
hypomagnesemia
5. Simvastatin reduces rate of cardiovascular events and
mortality by preventing plaque formation

Chapter

CONCLUSION

HEART
FAILURE
Diagnosed by
Framingham
criteria
(2 major, or 1 major
& 2 minor)

NOT ABLE TO PUMP,

OR ABLE TO DO, BUT
WITH HIGH PRESSURE
DIASTOLIC FILLING

The Patient has

2 major criteria,
and 1 minor
criteria

HIG
H
Morbidit
y
Mortality
EKG &
Radiologi
Thorax

Reference
1. AHA. 2013 .Guideline for the Management of Heart Failure: Executive
Summary A Report of the American College of Cardiology
Foundation/American Heart Association Task Force on Practice Guidelines
2. Douglas L, Douglas P, Zipes, Peter L, Robert O, Bonow. 2001. Braunwald's
Heart Disease: A Textbook of Cardiovascular Medicine, Single Volume, 8e
(Heart Disease (Braunwald) (Single Vol))8th Edition. Elsevier Saunders
3. Jay N. Cohn. 1996. The Management of Chronic Heart Failure. N Engl J Med
1996; 335:490-498
4. ESC. 2016. 2016 Guideline for the Diagnosis and Treatment of Acute and
Chronic Heart Failure. European Society of Cardiology.