CONGESTIVE HEART FAILURE (CHF) NYHA IV e.c Coronary Artery Disease (OMI Anteroseptal)

Patient IdentityName: Mr. SGender : MaleAge: 60 years oldMedical Record: Date of Admission: 11 January 2015Address:

Anamnesis Chief Complaint: Shortness of breathShortness of breath has been experienced since 2 years ago and worsened 1 week ago. It was experienced even the patient is at rest and relieved with ist own. The patient also complains chest pain which has been experienced since 7 years ago. Chest pain was felt on the left side of the chest with the characteristics of heavy feeling on the chest, duration of pain was < 5 minutes, did not radiate to the left arm and to the back.

Anamnesis The pain exacerbates with exercise and lessen with rest. Dyspnea on effort (+), Orthopnea (-), Paroxysmal Nocturnal Dyspnea (+), Cough (+) intermittent since 1 year ago. Palpitation (+), Fever (-) Nausea (-) Vomit (-). Defecation and urination: normal.

Past Medical HistoryThere is history of being admitted to the hospital 7 years ago with a diagnosis CAD and do installation balloons and rings .There is history of hypertension since 7 years ago but he doesnt take the drugs regularly.There is history of smoking since 35 years ago but stopped 7 years ago.1 box per day.There is no history of fever, congenital heart disease, thyroid disease, and diabetes mellitus. There is also no family history with cardiovascular disease.

Risk Factors

Physical ExaminationGeneral Status:Moderate illness/ Well nourished/ ConsciousNutritional Status: Normal (BMI: kg/m)Weight : 55 kg BMI: 20.2 kg/m2Height : 165 cm

Vital Signs:Blood Pressure: 130/60 mmHgPulse Rate: 80 bpmRespiratory Rate : 25 bpmTemperature : 36.7 0C

Head and Neck Examinations:Eye : Conjunctiva anemic (-/-), sclera icteric (-/-)Lip : cyanosis (-)Neck : No mass, no tenderness, JVP : R + 3 cmH2O

Chest ExaminationInspection: Symmetric left=right Palpation: No mass, no tenderness, vocal fremitus left=rightPercussion: Sonor left = right, lung-liver border in ICS VI right anteriorAuscultation: Breath sound : vesicular Additional sound : Ronchi - - Wheezing -/- - - + +

Physical Examination

Cardiac ExaminationInspection : Ictus cordis was not visiblePalpation: Ictus cordis was not palpablePercussion:Right heart border in right parasternal line, left heart border two fingers from left midclavicular line ICS VI.Auscultation: Heart sound: S I/II regular, no gallop, no additional sound

Physical Examination

Abdominal ExaminationInspection: flat, following breath movementAuscultation: Peristaltic sound (+), normalPalpation : No mass, no tenderness, no palpable liver and spleenPercussion: Tympani (+), ascites (-)Extremities ExaminationPretibial edema -/-Dorsum pedis edema -/-

Physical Examination

Electrocardiography(ECG)

Interpretation of ECGRhythm : Atrial fibrillationHR / QRS rate: 80 bpmAxis : Normoaxis Regularity : IrregularP wave : Difficult to assessPR interval : Difficult to assessQRS complex : 0.08 s (N: 0.06-0.11 s)Q pathologies : V1, V2, V3ST segment: Difficult to assessT wave: Difficult to assessConclusion : Atrial Fibrillation Normal Ventricular Response, OMI anteroseptal

Conclution of EchocardiographySystolic and diastolic dysfunction of the left ventricleEjection fraction 33%Left ventricular hypertrophyTrivial Mitral regurgitationThrombus in the left ventricle with a diameter 2.8 x 3.6 cmAkinetik basal anteroseptal, mid anteroseptal and anterior, apical anteroseptal, anterior, the other segments hipokinetik

Laboratory FindingComplete Blood Count Electrolyte

TestResultNormal valueWBC11.1/ul4.0 10.0 x 103RBC5.61/l4.0 6.0 x 106HGB16.7 gr/dl14 18HCT49.1%40 54 PLT290 000/l150 400 x 103

TestResultNormal valueNa146 mmol/l136-145K4.5 mmol/l3.5-5.1Cl113 mmol/l97-111

Laboratory FindingBlood ChemistryCardiac Enzymes

TestResultNormal valueGDS98 mg/dl

DiagnosisCHF NYHA IV e.c CAD (OMI Anteroseptal)Atrial Fibrillation Normal Ventricular Response (AF NVR)

ManagementO2 2-4 lpm via nasal canul IVFD NaCl 0.9% 10 dpmFluid BalanceInj. Furosemide 40 mg/12 hours/ IVFasorbid 10 mg 1-1-1 Aspilet 80 mg 0-1-0 Captopril 6,25 mg 1-1-1Simvastatin 1 x 20mg Digoxin 0.125 mg 1-0-0

PlanningECG control

DISCUSSIONCongestive Heart Failure (CHF)

DEFINITION

Major CriteriaMinor Criteria

Paroxysmal Nocturnal Dyspnea CardiomegalyGallop S3Hepatojugular refluxIncreased of JVPRales or ronchiAcute pulmonary edemaExtremity edemaNocturnal coughDecreased vital pulmonarycapacity (1/3 of maximal)HepatomegalyPleural effusionTachycardia ( 120bpm)Dyspnea deffort

Classification of CHF

Pathophysiology of CHF

Treatment of CHF

Coronary Artery DiseaseCoronary artery disease is a narrowing of the small blood vessels that supply blood and oxygen to the heart. (CAD) occurs when the arteries that supply blood to the heart muscle (the coronary arteries) become hardened and narrowed due to buildup of a material called plaque (plaque) on their inner walls. This is known as atherosclerosisEventually, blood flow to the heart muscle is reduced, and, because blood carries much-needed oxygen, the heart muscle is not able to receive the amount of oxygen it needs.

Causes CADCoronary artery disease (CAD) is caused by atherosclerosis (the thickening and hardening of the inside walls of arteries). Some hardening of the arteries occurs normally as a person grows older.In atherosclerosis, plaque deposits build up in the arteries. Plaque is made up of fat, cholesterol, calcium, and other substances from the blood. Plaque buildup in the arteries often begins in childhood.

Narrow the arteries. This reduces the amount of blood and oxygen that reaches the heart muscle. Completely block the arteries. This stops the flow of blood to the heart muscle. Cause blood clots to form. This can block the arteries that supply blood to the heart muscle.

Plaque in the arteries can be:Hard and stable. Hard plaque causes the artery walls to thicken and harden. This condition is associated more with angina than with a heart attack, but heart attacks frequently occur with hard plaque. Soft and unstable. Soft plaque is more likely to break open or to break off from the artery walls and cause blood clots. This can lead to a heart attack.

RISK FACTORS

INVESTIGATIONElectrocardiogram (ECG)Treadmill TestEchocardiographyCoronary AngiographyMulti-Slice Computed Tomography Scan (MSCT)Cardiac Magnetic Resonance Imaging (Cardiac MRI)Radionuclear Medicine

TREATMENT Lifestyle ChangesEat a healthy diet Quit smoking, if you smoke Exercise Lose weight, if you are overweight or obese Reduce stress

MedicinesCholesterol-lowering medicinesAnticoagulantsAspirinACE inhibitorsBeta blockersCalcium channel blockersNitroglycerinLong-acting nitrates

TREATMENT Special ProceduresAngioplasty (PTCA)Coronary artery bypass surgeryEnhanced External Counterpulsation (EECP)Cardiac RehabilitationExercise trainingEducation, counseling, and training

THANKYOU

**Chest pain was felt like being stabbed on the chest and last for less than 5 minutes of duration. Chest pain was also relieved by resting.

***************Major:Paroxysmal nocturnal dyspnoea Neck vein distension Rales Radiographic cardiomegaly Acute pulmonary oedema S3 gallop JVP > 16 cm H2O Hepatojugular reflux Circulation time > 25 seconds Weight loss 4.5 kg in 5 days in response to treatment of CHF Pulm.oedema, visc. congestion or cardiomegaly at autopsy

Minor:Bilateral ankle oedema Nocturnal cough Dyspnoea on exertion Hepatomegaly Pleural effusion Heart rate 120 bpm FVC decreased by 33% from max. value recorded

**disruption in any part of the mitral valve apparatusFor example: age, calcium build up around mitral annulus, dilatation of mitral annulus, mitral regurgitation***