Department of Cardiovascular

Case

Report
Faculty of Medicine
May 2015
Hasanuddin
University
Congestive
Heart Failure (CHF) NYHA III

e.c. Coronary Artery Disease (CAD)

By:
Miftah Farid Asmaun

Supervisor:

Dr. dr. Khalid Saleh, SpPD-KKV, FINASIM

PATIENTS IDENTITY
Name
Sex
Date of Birth
Age
Occupation
Date of Admission
Medical Record No.

:
:
:
:

Mr.Y
Male
31-12-1939
75 years old
: Farmer
: 11th May 2015
: 71.14.90

HISTORY TAKING
CHIEF COMPLAINT
Shortness of breath

HISTORY TAKING

Suffered since 3 months ago but worsened about a week

before admission to the hospital. Shortness of breath was
precipitated by activity, lying position, and sometimes suffered
suddenly during midnight. No chest pain at the moment but
there is a history of repeated chest pain that occur suddenly at
rest. Pain is intermittent and has tight and crushing quality. No
cough, no history of cough. No fever, no history of fever. There
are no nausea, vomiting, epigastric pain, and headache.

HISTORY TAKING
History of Previous Illness:
1. Previously treated in RS Toraja for 2 weeks with
complaint of chest pain and was diagnosed with
coronary heart disease before patient is referred to RS
Wahidin Sudirohusodo.
2. There is no history of hypertension.
3. History of diabetes mellitus is denied.
4. There is history of coronary artery disease.
5. There is history of smoking, 1 pack per day but had quit
smoking about 8 years ago.
6. There is no history of drinking alcohol.
7. History of heart disease in the family is denied.

HISTORY TAKING
Risk Factors:

Modified Risk Factors :

- smoking

Non-modified Risk Factor :

- age
- sex

PHYSICAL EXAMINATION
GENERAL STATE
Moderate illness/ well-nourished/ compos mentis

VITAL STATE
Blood Pressure

: 130/90 mmHg

Heart Rate

: 72 beats/minute

Respiratory Rate : 24 times/minute

Temperature

: 36,6OC

PHYSICAL EXAMINATION
REGIONAL STATE
Head :
Eye

: anemic (-), icteric (-)

Lip

: cyanosis (-)

Neck

: JVP R+2 cmH2O

Thorax :
Inspection

: symmetric left=right, normothorax

Palpation

: tenderness (-), tumor (-), vocal fremitus left=right

Percussion : sonor left = right

Auscultation : BS : bronchovesicular; ronchi +/+ on mediobasal of bilateral
lungs; Wheezing -/-

PHYSICAL EXAMINATION
Heart :
Inspection
Palpation
Percussion
Auscultation
Abdomen :
Inspection
Auscultation
Palpation
Percussion
Extremities
pedis -/-

: ictus cordis is not observed

: ictus cordis is not palpable
: dull, heart borders enlarged
: regular I/II heart sound, murmur (-)
: within normal limit
: peristaltic (+); normal
: tumor (-), palpable liver and
spleen (-)
: tympani, ascites (+-)
: edema: pretibial +/+ dorsum

DIAGNOSTIC
EXAMINATION
Electrocardiography
(ECG)

DIAGNOSTIC
EXAMINATION
Interpretation:
Rhythm

: Sinus rhythm

Heart Rate

: 69 bpm

Axis : normoaxis
P wave

: 0,04s

PR interval

: 0,16s

QRS duration : 0,06s; poor R wave progression

ST segment

: within normal limit

T wave

: T-inverted V2-V4

Conclusion

: sinus rhythm, heart rate 69 bpm, normoaxis, Q-wave on

V1-V3, poor R-wave progression

DIAGNOSTIC
EXAMINATION
LABORATORIUM
WBC

7,14 x 10 3
/L

RBC

5, 92 x 10 6
/L

PLT

329, 000/L

HGB

18, 0 g/dl

HCT

57, 4%

INR

1, 21

PT

12, 6 control 11, 7

APTT

26, 9 control 24, 6

DIAGNOSTIC
EXAMINATION
LABORATORY TEST
Natrium

141 mmol/L

Kalium

5, 1 mmol/L

Chloride

100 mmol/L

Troponin T

<0, 02/negative

DIAGNOSTIC
EXAMINATION

RADIOLOGY : Thorax Xray

Pulmo : Pulmonary edema with minimal bilateral pleural
effusion

Cardiomegaly with dilatatio et elongatio aortae

DIAGNOSTIC
EXAMINATION
ECHOCARDIOGRAPHY
Normal left ventricle systolic
function

Left ventricle diastolic

dysfunction grade 1

Concentric remodeling
Dilatation of RA and RV

RESUME
A 75 years old man admitted to the hospital with chief complaint dyspnea, suffered
since 3 months ago but worsened about a week before hospitalization. There are
dyspnea on effort (DOE), paroxysmal nocturnal dyspnea (PND), and orthopnea.
There is a history of chest pain occurring intermittently at rest with crushing and
tighten sensation.
History of previous illness:

Previously treated in RS Toraja for 2 weeks with complaint of chest pain and was
diagnosed with coronary heart disease before patient is referred to RS Wahidin
Sudirohusodo.

There is history of coronary artery disease.

There is history of smoking, 1 pack per day but had quit smoking about 8 years
ago.
On the physical examination: general state : moderate illness/well-nourished
composmentis;
blood pressure: 130/90 mmHg; non-anemic; ronchi +/+ on
mediobasal aspect of the lung; bilateral pretibial edema on both inferior
extremities.
Other examinations (EKG, laboratory test, thorax x-ray, and echocardiography)
supported the diagnosis of congestive heart failure et causa coronary artery

DIAGNOSIS
Congestive Heart Failure NYHA III et
causa Coronary Artery Disease

MANAGEMENT
O2 4 lpm via nasal canule
Connecta
Furosemid 40 mg/12 hours/intravena
Farsorbid 10 mg/8 hours/oral
Aspilet 80 mg/24 hours/oral
Captopril 6,25 mg/8 jam/oral
Omeprazole 40 mg/24 jam/oral

CONGESTIVE
HEART
FAILURE

INTRODUCTION
Along

with the advancement of medical

technology, since 1968, mortality rate of heart
failure has been decreasing.

Patients with heart failure survive for some years

with the better medications.

Although there is no exact number in Indonesia,

with the better health facility and medications, it is
predicted that the number of heart failure patient
will be increased each year.

ANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGY

ANATOMY AND PHYSIOLOGY

DEFINITION
Heart failure is an inability of the heart to
pump sufficient amount of blood to fulfill the
needs of body metabolism (forward failure)
or that the ability to pump can only be
obtained with high pressure from the blood
entering the heart (backward failure), or
both.

PREVALENCE
About 1980; Framingham : age-adjusted:
male = female.

Framingham : incidency (age adjusted) annually:

female = 0.14% and male = 0.23%.

Survival rate of the women is generally better

than of the men.

The increased incidency was about 100% with 1

decade of increasing age, reach the number of
3% for 85 - 94 years old patients.

ETIOLOGY
Coronary Artery Disease (CAD)
Hypertension
Cardiomyopathy

(dilatated,
restricted and obliterated)

Valvular heart disease

Alcohol consumption
Medications
Others

obstructed,

PATHOPHYSIOLOGY
Neurohormonal mech.

PATHOPHYSIOLOGY
ReninAngiotensinAldosterone system
mech.

PATHOPHYSIOLOGY
Sympathetic mech.

CLASSIFICATION
New York Heart Association (NYHA)
Functional Classification based on severity
and physical activity

DIAGNOSIS
Definitive diagnosis of congestive heart failure:

-At least 2 major criteria, OR

-1 major criteria + 2 minor criteria concurrently

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 oedema seen in x-ray;
6. gallop ventricular S(3);
7. Increased vein pressure > 16 cm H20;
8. Hepatojugular reflux;
9. Pulmonal oedema, visceral congestion, cardiomegaly found in autopsion;
10. Decreases body mass in CHF.

DIAGNOSIS
Minor criteria:
1. Bilateral ankle oedema;
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 pulmonal vascularization seen in x-ray.

EXAMINATIONS
1. Electrocardiography (ECG) :
Q wave, abnormality of T wave and ST segment,
LVH, bundle branch block, and atrial fibrillation.
2. Thorax X-ray : cardiomegaly, pulmonal
oedema.
3. Echocardiography : assess the heart structure
and function objectively.
4. Haematology and biochemistry

EXAMINATIONS
ECG

EXAMINATIONS
ECG

EXAMINATIONS
THORAX X-RAY

EXAMINATIONS
ECHOCARDIOGRAPHY

MANAGEMENT
NON-FARMACOLOGIC
-Education and counselling
-Diet
-Salt restriction
-Fluid restriction
-Avoid alcohol and cigar
-Perform regular activity which does not precipitate
the symptoms.

MANAGEMENT
FARMACOLOGIC
1. Decrease the preload:
diuretic, aldosterone receptors antagonist, nitrat
2. Increase heart contractility:
digitalis, ibopamin, -blocker gen.3
3. Decrease the afterload:
ACE-I, ARB, DRI, dihydropiridin CCB
4. Preventing miocard remodelling:
ACE-I, ARB

PROGNOSIS
Prognosis depends on:

- age
- etiology
- NYHA classification
- ejection fraction (EF)
- Comorbid conditions (renal dysfunction, diabetes, anemia,
hyperuricemia)

- Plasma natriuretic peptide concentration

THANK YOU