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Presented by: Dian Megawati R. L. B Supervisor : Dr. dr. Idar Mappangara, Sp.PD, Sp.JP.FIHA.


Department of Cardiology and Vascular Medicine Medical Faculty of Hasanuddin University Makassar 2013

Medical Record : 64-24-44 Name : Mr. AH Gender : Male Age : 68 years old Admininistered date: December 18th, 2013

Chief complaint : Shortness of breath

It was felt since 1 year before entering the hospital and getting worse in 1 day before admission. It was experienced while doing minimal activity such as walking to the bathroom and relieved with rest. Shortness of breath when sleep (+) patient used 2 pillows and often awakened because of that. Shortness of breath is also accompanied by pain in the middle of the chest, duration > 30 minutes, characterized with being pressured through the back, and radiating to the left arm and neck, and got lessen with rest. Palpitation (+), cold sweat (+), nausea (), vomiting (-), heartburn (-), fever (-), cough (-). Defecation : normal Urinary : normal

History of admission with the same complaint (+) 1 year ago without regular treatment History of hypertension (+) since 3 years ago without regular treatment History of diabetes mellitus ( - ) History of family with same disease ( - )

- Cigarette Smoking - Hypertension

- Gender : Man - Age : 68 y.o - Past heart disease

General Status Moderate Ilness/Well nourished/Conscious Body Weight :53 kg Body Height :165 cm Body Mass Index : 19,62 kg/m2 Vital Signs BP : 140/80mmHg HR : 90 bpm, regular RR : 26 bpm T : 36,5C

Head and Neck Examinations:

Eye Lip Neck : Conjunctiva anemic (-/-), Sclera icteric (-/-) : Cyanosis (-) : JVP R +2 cmHO

Chest Examination
Inspection: Symmetric between left and right chest. Palpation : No mass, no tenderness. Percussion : Sonor between left and right chest, lungliver border in ICS IV right anterior . Auscultation : Breath Sounds : Vesicular - Adventitious breath sound : Ronchi + /+ , wheezing -/-

Heart Examination o Inspection : IC was visible o Palpation : IC was palpable o Percussion : normal heart size Upper border : left 2nd ICS Lower border : left 6th ICS Right border : right parasternalis line Left border : left anterior axillaris line o Auscultation : Regular of I/II heart sound, murmur (-) Abdominal Examination o Inspection : flat and following breath movement o Auscultation : peristaltic sound (+) , normal o Palpation : liver and spleen unpalpable o Percussion : tympani, ascites (-) Extremities o Oedema

: pretibial (+/+) minimal, dorsum pedis (-)






15,76 4,19 12,4 34,6

4,00-10,0 4,00-6,00 12,0-16,0 37,0-48,0

(10/UI) (106/UI) (gr/dL) (%)

GDS Ureum Creatinin


140 10-50 <1,3

Mg/dL Mg/dL Mg/dL


SGOT SGPT Total Cholesterol HDL Cholesterol LDL Cholesterol Trygliceride

22 54 200 66 109 67

<38 <41 200 L(>55), P(>65) <130 200

mmol/L Mg/dL Mg/dL Mg/dL Mg/dL Mg/dL

CKMB Troponin T Natrium Kalium Chloride

42 0,20 119 4,2 94

<25 <0,05 136-145 3,5-5,1 97-111

U/L --mmol mmol mmol

Rhythm : Sinus Heart rate : 88 bpm Regularity : Reguler Axis : RAD P wave : 0,05 s PR interval : 0,16 s QRS complex : 0,16 s ST Segment : ST depression at lead V2,V3, V4, S wave widening at lead I, avL and V5, V6 T wave : Inverted at lead II, III, V2, V3, V4 Conclusion : Sinus rhythm, HR 88 bpm, Right axis deviation, infark anteroinferior wall, RBBB

Decreased of systolic LV function, EF 30% Dimensional chambers of heart : dilatation of LV & LA, SEC (-), thrombus (-) LVH (+) Global hypokinetic Good RV systolic function, TAPSE 2,0 cm Heart valves : - Aorta : 3 cuspis, calcification - Tricuspid : good function and movement - Pulmonal : good function and movement

Conclusion : LV systolic and diastolic disfunction, EF 30% Dilatation of LV & LA Global hypokinetic


Bed rest Oxygen 2-4 lpm via nasal canul IVFD NaCl 0,9% 500 cc/24 hours Diuretic Furosemide 20 mg/ 12 hours/iv ACE-I Captopril 3x12,5mg Nitrat Fasorbid (SL) 5 mg

Anti Platelet Aspirin 1x 80 mg Clopidogrel 1x 75 mg Anti Coagulant UFH 60 U/kgBB/ hour/ iv Digitalis Digoxin 1 x 0,25 mg Anti Cholesterol Simvastatin 1 x 20 mg Traguilizer Alprazolam 1 x 0,5 mg Laxans Laxadyne syrup 1 x 2 S


Heart Failure

Heart is no longer able to pump an adequate supply of blood in relation to the venous return and in relation to the metabolic needs of the body tissues at the particular moment The state in which abnormal circulatory congestion occurs as the result of heart failure.

Congestive Heart Failure

Etiology of Heart Failure

Main Causes Ischemic heart disease


Other Causes Arrhythmias Valvular heart disease Congenital heart disease Pericardial disease Hyperdynamic circulation Alcohol and drugs(chemotherapy)


Hypertension ( 15-20%)

Plaque in coronary artery

Blood flow to heart muscle is reduced. Heart muscle lacking of oxygen

Ischemia of heart muscle can lead to myocardial infarction

Symptomatic Congestive Heart Failure

Pulmonary edema, Abnormal Heart rhythm

The heart muscle cant pump adequately

Major Criteria
Paroxysmal Nocturnal Dyspnea Cardiomegaly Gallop S3 Hepatojugular reflux Increased of JVP Rales or ronchi Acute pulmonary edema Prolonged circulation time(> 25 sec) Weigh loss 4,5 kg in 5 days in response to treatment of CHF

Minor Criteria
Extremity edema Nocturnal cough Decreased vital pulmonary capacity (1/3 of maximal) Hepatomegaly Pleural effusion Tachycardia ( 120bpm) Dyspnea deffort

Coronary artery disease (CAD) is a narrowing or blockage of the arteries and vessels that provide oxygen and nutrients to the heart. It is caused by atherosclerosis, an accumulation of fatty materials on the inner linings of arteries. The resulting blockage restricts blood flow to the heart.



Stable Angina Pectoris




WHO Diagnostic Criteria:

Clinical history of ischemic type chest pain lasting >20 minutes. Changes in serial ECG tracings. Rise and fall of serum cardiac biomarkers such as creatinine kinase-MB fraction and troponin.

Substernal chest pain / chest discomfort radiated to the left arm, shoulder, neck, jaw. Penetrated to the back. The chest discomfort may also be described as a dull pain, pressure, squeezing or crushing sensation or burning sensation Duration more than 20 minutes. More intense and persistent. Not fully relieved by rest or nitroglycerine Often accompanied by systemic symptoms: nausea, vomiting, palpitation, fatigue, cold sweat, light headness

Cardiac Biomarkers Creatine Kinase (CK) Creatine Kinase Myocardiac Band (CKMB) Cardiac-specific Troponin T (cTnT) Cardiac-specific Troponin I (cTnI) Myoglobulin

Tissue Striated muscle, heart tissue, and brain Heart muscle, few in skeletal muscle

Normal Value Male (52-336 U/L) Female (38-176 U/L) <6.2 ng/mL (0.3%)

Myofibrilar protein found <0.01 ng/mL (<0.01 in myocardium g/L) Myofibrilar protein found <0.01 ng/mL (<0.01 in myocardium g/L) Myoglobulin found in 0.00-0.09 g/L (0-90 heme protein in smooth g/L) and skeletal muscle


Age 65-74 >/= 75

DM/HTN or Angina Exam SBP < 100

2 points 3 points
1 point 3 points

Total Score 0 1 2 3 4 5 6 7 8 9-14

Risk of Death in 30 days 0.8% 1.6% 2.2% 4.4% 7.3% 12.4% 16.1% 23.4% 26.8% 35.9%

HR > 100
Killip II-IV Weight > 67 kg Presentation

2 points
2 points 1 point

Anterior STE or LBBB

Time to treatment > 4 hrs Risk Score = Total

1 point
1 point (0-14)