Presentasi Kasus

Oleh:
dr. Adilla Mega Sari
Nama : Nyonya S
Jenis kelamin : Perempuan
Usia : 56 tahun
Alamat : Patih Galung, Prabumulih Barat
Pekerjaan : Ibu Rumah Tangga
Status : Menikah
Agama : Islam
MRS : 19 Maret 2016
sesak yang semakin memberat
sejak ± 2 hari SMRS.
 2 hari SMRS
• Sesak nafas
• Saat berjalan jauh
• Terbangun malam • Sesak saat ke kamar mandi
• Tidur dg bantal tinggi • Menetap saat istirahat
• Nyeri kepala • Tidur dengan posisi
setengah duduk
2 minggu
• Mual
SMRS • Bengkak pada kaki
• Perut terasa membesar
• Penurunan nafsu makan
Keadaan Umum
 Keadaan sakit/ kesadaran : Tampak sakit sedang / CM
 Tekanan darah : 200/130 mmHg
 Nadi : 96 x/ menit, reguler, isi & tegangan cukup
 Pernapasan : 32 x/ menit
 Temperatur : 36,7ºC
 BB / TB : 65 kg / 150 cm
 BMI : 28,8 kg/m2
 Paru :
A: HR 96 x/ menit, I: simetris
Kepala: Jantung :
bunyi jantung I & II P:cordis
Stem fremitus
Konjungtiva I: Ictus tidak terlihat
reguler, murmur
Leher:sistolik lapangan bawahlinea
Abdomen : di katup
palpebra pucat P: Ictus cordis teraba
grade 2/6
JVP (5+2) cmH aorta
2O kanan kiri meningkat
I:Cembung axilaris anterior sinsitra ICS VI
dan pulmonal; grade P: Redup
P:Lemas, P: Batas jantungdikanan
kedualinea
3/6 di hepar
katup dan lien
mitral dan basal paru
tidak teraba gallop tidak parasternalis dextra, batas
trikuspid, A: kiri
rokhi basah halus
P:Timpani, didapatkan jantung linea axillaris
ada pada basal ICS
kedua
shifting dullness anterior sinistra VI
A:BU normal paru

Ekstremitas:
Edema (+/+)pretibial,
telapak tangan pucat (+)
 Kriteria Mayor Kriteria Minor
Paroxysmal nocturnal dyspne(+) Edema ekstremitas (+)
Distensi vena leher (+) Batuk malam hari (-)
Ronkhi paru (+) Dispneu d’effort (+)
Kardiomegali (+) Hepatomegali (-)
Edema paru akut (+) Efusi pleura (-)
Gallop S3 (-) Penurunan kapasitas vital 1/3
Peninggian tek vena jugularis (+) dari normal (-)
Refluks hepatojugular (-) Takikardi (>120 x/menit) (-)
No. Pemeriksaan Hasil Nilai Normal

1. Hemoglobin 4,8 g/dl 12-16 g/dl

2. Hematokrit 14,5 vol % P:37-43 vol%
3. Leukosit 7.000/µl 5.000-10.000/µl

4. Eritrosit 4,8 juta/ µl 4,2-5,4 juta/ µl

289.000/
5. Trombosit 200000-500000 mm3
mm3
0/0/0/87/1
6. Hitung jenis 0-1/1-3/50-70/20-40/2-8
3/0
No. Pemeriksaan Hasil Nilai Normal
1. BSS 103mg/dl 76-130 mg/dl
2. SGOT 18 U/l < 31 U/l
3. SGPT 20 U/l < 34 U/l
4. Ureum 146 mg/dl 10-50 mg/dl
5. Creatinin 4,0 mg/dl 0,5-0,9 mg/dl
6. Asam urat 12,0 2,4-5,7 mg/dl
7. Na 129 mmol/l 136-146 mmol/l
8. K 6,63 mmol/l 3,5-5 mmol/l
9. Cl 106 mmol/l 95-108 mmol/l
10. Kolesterol Total 90 mg/dl < 220 mg/dl
11. Trigliserida 60 mg/dl < 150 mg/dl
INTERPRETASI :
 Sinus ritme, HR : 92 x/m, normal axis, S di V1 + R di V5/6 <
35mm, left atrial enlargement, T-Inverted V1-V2, R di V1 + S
di V5/6 < 35 mm, durasi QRS 0,06.
Kesan : Abnormal ECG →left atrial enlargement, iskemik septal
Expertise Spesialis Radiologi :
 Kesan : - CTR > 50%  Kardiomegali
 Corakan bronkovaskular meningkat di basal paru kanan &
kiri
Congestive Heart Failure e.c Hypertensive
Heart Disease susp. penyakit ginjal kronik +
Hipertensi Emergensi + Edema Paru Akut+
Anemia Penyakit Kronis
 Non-Farmakologis
• Istirahat tirah baring dan
observasi tanda-tanda vital
• Diet tinggi kalori, rendah
protein dan rendah garam
• Pembatasan asupan cairan
oral dan/atau intravena
(500-800 ml/hari)
• Pemasangan kateter urin
dan pengukuran balance
cairan (target negatif)
• Pemeriksaan elektrolit
Natrium, Kalium dan Fosfat
harian
Farmakologis
• O2 Nasal Kanul 3 l/menit
• IVFD RL gtt vi/menit mikro
• Furosemide 2 x 20 mg Amp IV
• Captopril 2x25 mg
• Candesartan 1x8 mg
• Digoxin 1x1 tab
• Spironolakton 2 x 25 mg tab
(diberikan bila edema tidak
berkurang, dengan syarat
Kalium < 5 mmol/l)
• Asam Folat 1 x 400 mcg tab
• Ca Gluconas 1 Amp (bila saat
cek harian Kalium > 5 mmol/l)
• Transfusi packed red cell
 Quo ad
Quo ad vitam :
functionam :
Dubia ad Malam
Dubia ad Malam
 Heart (or cardiac) failure is the state in which
the heart is unable to pump blood at a rate
commensurate with the requirements of the
tissues or can do so only from high pressures

Braunwald 8th Edition, 2001

 5 million Americans have heart failure
 500,000 new cases of symptomatic heart failure
annually
 20% of hospital admissions among persons older
than 65
 45% annual mortality in severe symptomatic heart
failure
 More Medicare dollars are spent for diagnosis and
treatment of heart failure than for any other single
diagnosis.
 Lebih banyak terjadi pada usia lanjut
 1% dari penduduk usia 50 tahun, sekitar 5%
dari mereka berusia 75 tahun atau lebih, dan
25% dari mereka yang berusia 85 tahun atau
lebih.
 Dari survei registrasi rumah sakit didapatkan
angka perawatan di rumah sakit, dengan
angka kejadian 4.7% pada perempuan dan
5.1% pada laki-laki.
 Primary risk factors
◦ Coronary artery disease (CAD)
◦ Advancing age
 Contributing risk factors
◦ Hypertension
◦ Diabetes
◦ Tobacco use
◦ Obesity
◦ High serum cholesterol
◦ African American descent
◦ Valvular heart disease
◦ Hypervolemia
◦ 1. Impaired cardiac function
 Coronary heart disease
 Cardiomyopathies
 Rheumatic fever
 Endocarditis
◦ 2. Increased cardiac workload
 Hypertension
 Valvular disorders
 Anemias
 Congenital heart defects
◦ 3.Acute non-cardiac conditions
 Volume overload
 Hyperthyroid, Fever,infection
ACC/AHA Stages

NY ASSN Funct Class

U Upright Position
N Nitrates

L Lasix
O Oxygen
A ACE, ARBs, Amiodorone
D Dig, Dobutamine

M Morphine Sulfate
E Extremities Down
 Exercise training for stable HF patients increased exercise
capacity, decreased hospitalization rate, increased quality of
life, decreased symptoms.
 Weight loss in obese patients
 Dietary Na restriction (≤ 2 g/day)
 Fluid and free water restriction (≤ 1.5 L/day) especially if
hyponatremic
 Minimize medications known to have deleterious effects on
heart failure (negative inotrops, NSAIDs, over-the-counter
stimulants)
 Oxygen
 Fluid removal (dialysis, thoracentesis, paracentesis)
Stages of Heart Failure and Treatment Options for Systolic Heart Failure

Jessup M and Brozena S. N Engl J Med 2003;348:2007-2018


Stage A At high risk for developing heart failure.
Includes people with:
Hypertension
Diabetes mellitus
CAD (including heart attack)
History of cardiotoxic drug therapy
History of alcohol abuse
History of rheumatic fever
Family history of CMP
Stage B Those diagnosed with “systolic” heart
failure- have never had symptoms of heart
failure (usually by finding an ejection
fraction of less than 40% on
echocardiogram
Stage C Patients with known heart failure with
current or prior symptoms.
Symptoms include: SOB, fatigue
Reduced exercise intolerance
Stage D Presence of advanced symptoms, after
assuring optimized medical care
Therapies
Exercise regularly
Quit smoking
Treat hypertension
Treat lipid disorders
Discourage alcohol or illicit drug
use
If previous heart attack/ current
diabetes mellitus or HTN, use ACE-
I
Care measures in Stage A +
Should be on ACE-I
Add beta -blockers
Surgical consultation for coronary
artery revascularization and valve
repair/replacement (as appropriate
All care measures from Stage A apply,
ACE-I and beta-blockers should be used +
Diuretics, Digoxin,
Dietary sodium restriction
Weight monitoring, Fluid restriction
Withdrawal drugs that worsen
condition
Maybe Spironolactone therapy
All therapies -Stages A, B and C +
evaluation for:Cardiac transplantation,
VADs, surgical options, research
therapies, Continuous intravenous
inotropic infusions/ End-of-life care
 Type What it does
•ACE inhibitor (angiotensin- •Expands blood vessels which lowers blood
converting enzyme) pressure, neurohormonal blockade

•ARB (angiotensin receptor •Similar to ACE inhibitor—lowers blood

blockers) pressure

•Beta-blocker •Reduces the action of stress hormones

and slows the heart rate
•Digoxin •Slows the heart rate and improves the heart’s
pumping function (EF)

•Diuretic •Filters sodium and excess fluid from the blood to

reduce the heart’s workload

•Aldosterone blockade •Blocks neurohormal activation and controls

volume
 Improve Symptoms  Improve Survival
◦ Diuretics (water pills) ◦ Betablockers
◦ digoxin ◦ ACE-inhibitors
◦ Aldosterone blockers
◦ Angiotensin receptor
blockers (ARB’s)
 What Why
•Eat a low-sodium, low-fat diet •Sodium is bad for high blood pressure,
causes fluid retention

•Lose weight •Extra weight can put a strain on the

heart

•Stay physically active •Exercise can help reduce stress and

blood pressure

•Reduce or eliminate alcohol •Alcohol and caffeine can weaken an already

and caffeine damaged heart

•Quit Smoking •Smoking can damage blood vessels and make

the heart beat faster