chf nyha iiii
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KONSULEN:
Dr. dr. Idar Mappangara, SpPD,
SpJP.FIHA.FINASIM
PRESENTER:
NOR HAZIRAH BINTI OMAR
C 111 09 846
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IDENTITY OF PATIENTName : Mr. R
Age : 64 y.o
Gender : MaleAddress : Daya
MR : 443141
Date of admittance : 9 September 2013
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ANAMNESIS Chief Complaint :Shortness of breath (SOB)
Brief Anamnesis :
The onset of SOB was 1 month before admittingin hospital. It worsens 1 day before admitting inhospital. It worsens during any physical activitiessuch as lifting up things (DOE). He also
experiences SOB whenever he lies down and withmild exertion. Patient complains that he oftenwakes up in the middle of night and gasps for air(PND) and he feels better if use two to threepillows while sleeping (orthopnea). He says that
wheather does not influence SOB.
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ANAMNESIS Patient complaints that his both legs was swollen.
The onset was 1 week before admitting in hospital.
Cough (+), white serous, appears since 1 week ago Chest pain (-), History of chest pain (+), 10 years ago,
doctor advise the patient to do catheterization to putin two stent but the patient refuse to do so.
Fever (-), History of fever (-) Nausea (-), Vomit (-)
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PAST MEDICAL HISTORY History of shortness of breath in June 2013 (+) was
admitted in hospital
Hypertension (-)
Diabetes mellitus (-)
Cigarette smoking (+) 20 years
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Present status:
Moderate illness / Well-nourished / Conscious
Vital signs:
BP : 100/70mmHg
HR : 92bpm
RR : 36x/minT : 36,5C
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Regional status
Head Examination
- Eyes : Anemis (-), Icterus (-)
- Lip : Cyanosis (-)
- Neck : JVP R +2 cmH2O, enlargement of thyroid gland (-)
Chest Examination
- Inspection : Symmetric sinistra et dextra
- Palpation : No mass, no tenderness, VF sinistra = dextra
- Percussion : Sonor sinistra et dextra
Lung-liver border in ICS VI right anterior
- Auscultation : Breath Sound = Bronchovesicular
Additional Sound = Rh , Whz -/-
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Cardiac Examination
Inspection : Ictus cordis not visible.
Palpation : Ictus cordis not palpable
Percussion : Right heart border in right parasternal line,left heart border in left midclavicle line ICS V.
Auscultation : Heart Sounds = S I/II regular , murmur (-)
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Abdominal- Inspection : flat, following breath movement,
ascites (+)
- Auscultation : peristaltic sound (+), normal
- Palpation : liver unpalpablespleen unpalpable
- Percussion : shifting dullness (+)
Extremities
- Oedema pretibial +/+
- Oedema dorsum pedis +/+
- Cyanosis (-), Clubbing finggers (-)
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ELECTROCARDIOGRAPHY
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Intrepetation of ECG :Rhythm : Sinus
Heart rate : 104 bpm
Regularity : Reguler
PR interval : 0,08
P wave : Normal
Axis : RAD (180)
Complex QRS : The height of R wave > S wave at V1
: Pathologic Q wave at V2
V4Duration QRS : 0,08
T wave : inverted at V1V3
Conclusion : Sinus tachicardia, HR 104/mnt, RAD,
RVH, OMI anteroseptal, low voltage
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Types of test Results Normal Value
Routine Blood Test WBC 7,26 x 10^3/uL 4,00-10,00
PLT 121 x 10^3/uL 150-400
RBC 5,2 x 10^6/uL 4,00-6,00
HGB 15,9 13,0-16,0 g/dL
HCT 24,7 37,0-48,0 %
Blood Chemistry GDP 76 110 mg/dl
Ur 52 10-50 mg/dlCr 1,1
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Types of test Results Normal Value
Cardiac Enzyme CK 60
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CHEST-XRAYConclusion:
Cardiomegaly with signs
of pulmonary edema
Dilatation of aortae
Right pleural effusion
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USG Bilateral Pluera Effusion
especially at right
Ascites
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WORKING DIAGNOSIS
1. Congestive Heart Failure NYHA III ec
CAD
2. Hipoalbumin
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MANAGEMENT
Heart Diet
IVFD NaCl 0,9% 10 drips/min O2 24 liter/min
Furosemide 200mg/24h/IV
Aspilet 80mg 1-0-0
Farsorbid 10mg 1-1-1 Captopril 6,25mg 1-1-1
Alprazolam 0,5mg 1-0-0
Simvastatin 20mg 0-0-1
Laxadin Syrup 0-0-2C
Infus albumin 20% 1 bottle/24 hours
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PLANNING
ECG Control
Chest X-Ray
Lab Examination
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Ong, WT; Patacsil, GB. Cardiology Blue Book: 148
Heart no longer able to pump an
adequate supply of blood in
relation to the venous return and inrelation to the metabolic needs of
the body tissues at the particularmoment
HeartFailure
The state in which abnormal
circulatory congestion occurs asthe result of heart failure.
CongestiveHeart
Failure
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EtiologyIschemic heart disease
Valve disease
Hypertensive heart disease
Cardiomyopathy
Coronary artery disease
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NYHA CLASSIFICATION
Classification Description
NYHA I -No limitation o f physical activity
-No symptoms with ordinary exertion
NYHA II -Slight limitation of physical activity
- Ordinary activity causes symptoms
NYHA III -Marked limitation of physical activity-Less than ordinary activity causes symptoms
-Asymptomatic at rest
NYHA IV -Inability to carry out any physical activity without discomfort-Symptoms at rest
i d
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Signs and Symptoms
Company LogoThe National Heart, Blood, and Lung Institute. cited from http://fromyourdoctor.com/.Last updated June 7,
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Diagnosis
NB : To establish a clinical diagnosis of congestive heart failure by these criteria, at least one major
and two minor criteria are required.
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TREATMENT
Managing
afterload
Managing
preload
Neurohormonal
modulation
Managing
contractility
Inotropic agents :Cardiac glycosidesB- adrenergic Phosphodiesteraseinhibitors
Diureticsvenodilator
Ca2+channelblockers
Antiadrenergic
Vasodilators
blockersACE inhibitorsAngiotensinreceptorblockers
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CORONARY ARTERY DISEASE
DEFINITION
Condition in which plaque builds up insidethe coronary arteries. These arteries supply
oxygen-rich blood to the heart muscle.
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CAUSES
The major underlying cause is atherosclerosis.
It is a slow, progressive disease which begins
in childhood and takes decades to advance.
It occurs when plaque builds up in the arteries.
The buildup of plaque occurs over many years. Over time, plaque hardens and narrows your
coronary arteries. This limits the flow of
oxygen-rich blood to your heart muscle.
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Endothelial Injury
Monocytes becomes macrophages
Activate macrophages release free radicals
Oxidize LDL
Toxic to endothelium causing endothelial loss
Exposure of subendothelial connective tissue to blood components
Platelet adhesion & aggregation fibrin deposition
Platelet release various factor
Smooth muscle migrates into intima & proliferate
Smooth muscle cell, macrophages & matrix accumulate LDL from the plasma
ATHEROMATOUS LESION
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PATHOPHYSIOLOGY
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RISK FACTOR
Modifiable:
- Smoking
- Dyslipidemia (Raised LDL-
C, Low HDL-C, Raised
triglycerides)
- Raised Blood pressure
- Diabetes melitus
- Obesity
Non-Modifiable :
Personal History of CVD
Family History of CVD
Age
Gender
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CLASSIFICATION
STEMI NSTEMISTEMI
Non Q wave MI
NSTEMI
Q wave MIUnstable angina pectoris
Coronary Artery Disease
Acute Coronary SyndromeStable angina pectoris
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Unstable Plaque Occlusive Thrombus
Fixed Coronary Obstruction(Chronic Ischemic Heart Disease)
PATOGENESIS
Si &
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Sign & symptoms
Stable angina
Discomfort in the chest, jaw,shoulder, back or arms,
Typically elicited by exertion oremotional stress and relieved by
rest or nitroglycerin.
Less typically, discomfort mayoccur in the epigastric area.
Unstable anginaAngina at rest (> 20 minutes)New-onset (< 2 months)exertional angina (at least CCSCIII in severity)Recent (< 2 months)
acceleration of angina (increasein severity of at least one CCSCclass to at least CCSC class III)
MI
Prolonged chest pain
Associated symptoms from the
autonomic nervous system (nausea,
vomiting, diaphoresis)
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DIAGNOSIS
Electrocardiogram (ECG)
Echocardiogram
Stress test
Cardiac catheterization or angiogram
Magnetic resonance angiography (MRA)
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TREATMENT GOAL:
Improve prognosis by preventing myocardial infarction and
death
Minimize or abolish symptoms.
NON PHARMACOLOGY:
Lifestyle modification
Quit smoking
Exercise regularly
Lose excess weight
Avoid stress
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Nitrates
Beta blockersCa antagonist
HeparinLMWHWarfarin
AspirinThienopiridinesGPIIb/IIainhibitor
Anti CoagulantAnti Platelet
Anti ThromboticAnti Ischemic
Pharmacological
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THANK YOU
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