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

Case ReportSeptember, 2015

Cardiovascular DepartmentFaculty of MedicineUniversitas Hasanuddin

Patient’s Identity

• Name : Mr. SD• Age : 77 years old• MR : 723072• Address : Mamasa• Admitted : August 21st, 2015

History Taking

• Chief complain: Breathless• Suffered since 4 years, worsen 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 (-)

• Hypertension (+) since 10 years ago (consumes anti-hypertension irregularly)

• Diabetic mellitus(-)• Previous heart disease(+)• Family history of heart disease (-) • Smoking (+), alcoholic (-)

History Taking

• Modifiable: – Smoking, – Hypertension

• Non modifiable:– Age (77 y.o)– Gender (male)

Risk Factors

• General state: – moderate illness, poor-nourished, compos mentis

• BMI: 18,35 kg/m2 (overweight)• Vital signs:

– BP: 120/90 mmHg– HR: 72 bpm– RR: 22 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 : tympani

• Extremities :– Edema (-)

Physical Examination

ECG

Laboratory Finding

August 21st, 2015

Laboratory Findings

Radiology Findings

• Chest X-Ray(August 22nd, 2015)

Cardiomegaly with dilatatio et elongatio aortae

Radiology Findings

• Abdominal USG(August 25th, 2015)– Prostate

hypertrophy– Right kidney cyst

Radiology Findings

-Left ventricle systolic and diastolic disfunction

-Segmental hypokinetic-Concentric left ventricle

hypertrophy-Mild aortic regurgitation

Echocardiography

• Congestive Heart Failure NYHA III Post Acute Lung Oedema

• Non-ST-Segment Elevation Myocardial Infarction

Assessments

1. Oxygen 6 lpm via simple mask2. IVFD NaCl 0,9% 500 cc/24 hours/IV3. Furosemide 200 mg/24 hours /syringe pump4. Aspilet 80 mg/24 hours oral5. Clopidogrel 75 mg/24 hours /oral6. Cedocard 1mg/hour/syringe pump7. Isosorbid dinitrate 5mg/sublingual if pain8. Arixtra 2,5mg/24 hours/subcutan

Management

DISCUSSION

1. Congestive Heart Failure2. NSTEMI

Definition

• Forward failure• Backward failure• Or both

CONGESTIVE HEART FAILURE

Causes

CONGESTIVE HEART FAILURE

• Myocard dysfunction:– CAD– Cardiomyopathy– Myocarditis and rheumatic heart disease– Infiltrative disease– Iatrogenic

• Mechanic dysturbance– Pressure overload– Volume overload– Filling defect

Causes

CONGESTIVE HEART FAILURE

Case:History Taking:- Shortness of breath- DOE (+)- PND (+)- Orthopnea - Cough

Physical Examination- JVP increasing- Rales

Radiology Findings- Chest X-ray: cardiomegaly followed by pulmonary edema sign- Abdominal USG: right pleural effusion

Pathophysiology

CONGESTIVE HEART FAILURE

Case:History Taking:- Shortness of breath- DOE (+)- PND (+)- Orthopnea - Cough

Physical Examination- JVP increasing- Rales

Radiology Findings- Chest X-ray: cardiomegaly followed by

pulmonary edema sign- Abdominal USG: right pleural effusion

New York Heart Association (NYHA)

Classification

CONGESTIVE HEART FAILURE

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 H20;

8. Hepatojugular reflux;9. Pulmonary edema, visceral congestion, cardiomegaly found in autopsy; 10. Body mass decreasing

Diagnosis

CONGESTIVE HEART FAILURE

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.

Diagnosis

CONGESTIVE HEART FAILURE

At least 2 major criteriaOR

1 major criteria + 2 minor criteria concurrently

Definitive Diagnosis

CONGESTIVE HEART FAILURE

CaseHistory Taking:- Chest paint- Blunt- Suddenly- Provoked by activity (-)- Cold sweat

ECG:- ST-segment depression- Poor R-wave progression

Laboratory Findings:- Cardiac biomarkers/enzymes

increasing

Definition

NSTEMI

Pathophysiology

NSTEMI

Diagnosis

WHO criteriaAt least 2 points:- Typical chest pain- ECG record- Cardiac biomarkers/enzymes increasing

Diagnosis

NSTEMI

Therapy

Goal• Hemodynamic stabilization• Pain relief• Reperfusion• Prevent complications

Therapy

NSTEMI

Thank You