CHF NYHA III-IV ec.

Coronary Artery
Disease
Presenter: A. Wetenri Padauleng
Supervisor: Dr. Pendrik Tandean, SpPD

PATIENT IDENTITY

Name
: Mr. MT
No.MR
: 37 75 57
Age
: 48 y.o
Gender
: Male
Occupation : Village chief
Address
: Terang-terang St.-Gowa
Date of admittance : 8th Feb 2009

HISTORY
Chief complaint : dyspnea
It has been felt since a year ago & getting worse hours before
admittance. It was felt if he walked till 10 m of distance & also
precipitated by activity & emotional stress. It often occurred while
sleeping in the night & getting better if he used 2-3 pillows. There
was also productive cough which sometimes with a clear sputum &
sometimes with a pink sputum. There were also swelling on both of
legs (dorsum pedis edema) since 3 days ago before admittance. It
wasnt precipitated by weather changes. There were no history of
chest pain, fever, headache, dizzines, nausea, vomitting & upper
abdominal pain. Urinate & defecate were normal.

PAST MEDICAL HISTORY

Hypertension had been known since a
year ago (T: 180/..mmHg), not under control
regularly.
Diabetes mellitus since 2001, on
treatment regularly with glibenclamide.
Cardiac disease since a year ago, not
under control regularly.

RISK FACTOR

Male gender
Age (48 y.o)
Family history
Sedentary lifestyle eg. smoking since 30 years
ago; 1 pack/day
Dyslipidemia
Hypertension
Diabetes mellitus

PHYSICAL EXAMINATION

Status present : Severe-illness/Overweight/Conscious

Vital Sign :
Blood pressure
Pulse
Inspiratory rate
Body temperature

: 180/70 mmHg
: 112x/min
: 40x/min
: 36.7oC

Head Examination :
Eyes : there was anemis, no cyanosis, no icterus
Neck : JVP R+2 cmH20, there were no mass & tenderness

Thoracal Examination :
Inspection
: Symmetric
Palpation
: No mass; no tenderness
Percussion : Sonor on the right hemithorax & dull on the left hemithorax (on the base of
lung untill ICS ..); hepatopulmonary borderline on ICS IV.
Auscultation : Breath Sound : vesicular
Additional sound :Ronchi -/+, Wheezing -/-

PHYSICAL EXAMINATION
Heart Examination :
Inspection

Palpation
Percussion
Auscultation

: ictus cordis was invisible

: ictus cordis was impalpable
: normal
: regular of I/II heart sound; no murmur

Abdominal Examination :
Inspection
Palpation
Percussion
ascites
Auscultation

: normal
: no mass; no tenderness
: shifting dullness (+) moderate
: peristaltic sound (+); normal

Extremities : there were swelling on both of legs.

ADDITIONAL EXAMINATION
Laboratory test
Complete blood (8th Feb 09)
WBC : 25.8 x 103 /mm3
RBC : 4.25 x 106 /mm3
HGB : 10.7 g/dl
HCT : 32.9 %
PLT : 531x 103 /mm3
Blood electrolytes (8th Feb 09)
Sodium
: 130 mmol/l
Potassium
: 5.9 mmol/l
Chloride
: 100 mmol/l
Heart enzymes (9th Feb 09)
CK
: 1438
CKMB
: 49 U/l
Troponin-T
: positive 0.62 nm/l

Blood chemistry (8th Feb 09)

Random glucose
: 133 mg/dl
Fasting glucose
: 160 mg/dl
Post prandial glucose
: 244 mg/dl
SGOT
: 89 U/l
SGPT
: 14 U/l
Cholesterol total
: 252 mg/dl
Cholesterol HDL
: 25 mg/dl
Cholesterol LDL
: 134 mg/dl
Triglyseride
: 144 mg/dl
Ureum
: 104 mg/dl
Creatinin
: 3.3 mg/dl
Uric acid
: 10.0 mg/dl

ECG

ECG
Interpretation :
Sinus tachycardia
Anteroseptal MCI
Lateral et inferior myocardial ischaemic
LVH

ADDITIONAL EXAMINATION
ECG :
- Sinus tachycardi; HR : 110x/min
- Anteroseptal MCI
- Lateral et inferior myocardial ischaemic
- LVH

SUGGESTION ADDITIONAL
EXAMINATION
Chest X-Ray
Coronary arteriography
Echocardiography

WORKING DIAGNOSIS
Acute Coronary Syndrome
DM type 2 non-obese

DIFFERENTIAL DIAGNOSIS
Pneumonia
Tuberculosis pulmonal

MANAGEMENT

O2 4-6 L/min
Heart & DM diet
NaCl 0.9%
Lasix 2 amp/12 h/i.v
Lasix 2 amp/24 h/sp
NTG 20 mg/kgBB/sp
Actrapid 6-6-6 sc

DISCUSSION
Actually, clinical manifestation of CHF lead to decrease CO
or congestion of pulmonary or systemic vein.

CHF - Systolic dysfunction

- Diastolic dysfunction

DISCUSSION
Etiology :
Contractility disturbance (eg. myocardial
infark; temporary myocardial ischaemic;
chronic volume overload such as mitral &
aortic regurgitation).
Cardiomyopathy
Pressure overload (eg. aortic stenosis;
uncontrolled hypertension)

DISCUSSION
Clinical manifestations are :
Fatigue, weakness.
Dyspnoea
Orthopnoea
Paroxysmal Nocturnal Dyspnoea (PND)
Cough
Nocturia
Anorexi
Right upper quadrant (epigastric) dyscomfort

Coronary Artery Disease

Occluded of the coronary artery

Partial
Total
1 coronary artery and branches
Blood flow

Kuliah PJK, 2004

DISCUSSION
Risk Factors for cardiovascular disease :

Modifiable :
- Smoking
- Dyslipidemia (Raised LDL-C & TGs; Low HDL-C)
- Raised Blood pressure
- Diabetes mellitus
- Obesity
Non-Modifiable :
- Personal History of CVD
- Family History of CVD
- Age
- Gender

DISCUSSION

Major factors Hypertension

Secondary factors

Elevated serum cholesterol

Cigarette smoking
Male gender
Increasing age
Previous history of coronary heart disease

Glucose intolerance

Left ventricular hypertrophy

Family history of coronary heart disease
Lack of exercise
Excessive alcohol consumption
Obesity

Other factors Contraceptive pill

Stress
Personality

Insulin resistance, dyslipidemia & cardiovascular disease

INSULIN
RESISTANCE

decrease

Uptake of glucose from

blood into cells

increase

increase
increase

Blood glucose
levels

increase

Hypertrophy of
vascular smooth
muscle and left
ventricle

Blood insulin
levels
decrease

increase

Blood LDL-cholesterol
and VLDL-cholesterol
levels
increase

Blood pressure

Blood HDLcholesterol
levels

increase
Atherosclerosis
and risk of coronary
heart disease
DeFronzo & Ferrannini (1991)

DISCUSSION
Non-pharmacological Th/ :
Stop cigarette smoking
Mediterranean diet, with vegetables, fruit, fish and
poultry being the mainstays.
Weight reduction diet --- Overweight
Fish oil rich in omega-3 fatty acids (n-3 polyunsaturated
fatty acids) are recommended at least once weekly
Physical activity within the patients limitation should be
encouraged.
Concomitant disorders such as diabetes and hypertension
should be managed appropriately.

DISCUSSION

Pharmacological Th/:

First-line agents
Angiotensin-converting enzyme (ACE) inhibitors
Diuretics
Beta-adrenoceptor antagonists
Aldosterone receptor antagonists
Angiotensin receptor antagonists
Second-line agents
Cardiac glycosides
Vasodilator agents (nitrates/hydralazine)
Positive inotropic agents
Anticoagulation
Antiarrhythmic agents
Oxygen