Presented by:Dian Megawati R. L. B

Supervisor :Dr. dr. Idar

Mappangara, Sp.PD, Sp.JP.FIHA.FINASIM

Department of Cardiology and Vascular Medicine

Medical Faculty of Hasanuddin UniversityMakassar

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 ( - )

• 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 : 36,5˚C

Head and Neck Examinations:• Eye : Conjunctiva anemic (-/-), Sclera icteric (-/-) • Lip : Cyanosis (-)• Neck : JVP R +2 cmH₂O

Chest Examination• Inspection : Symmetric between left and right chest.• Palpation : No mass, no tenderness.• Percussion : Sonor between left and right chest, lung-

liver border in ICS IV right anterior .• Auscultation :

Breath Sounds : VesicularAdventitious breath sound : Ronchi +-/+-, wheezing -/-

Heart Examinationo Inspection : IC was visibleoPalpation : IC was palpableoPercussion : normal heart size

Upper border : left 2nd ICS Lower border : left 6th ICS Right border : right parasternalis line Left border : left anterior axillaris line

oAuscultation : Regular of I/II heart sound, murmur (-)

Abdominal Examinationo Inspection : flat and following breath movementoAuscultation : peristaltic sound (+) , normaloPalpation : liver and spleen unpalpableoPercussion : tympani, ascites (-)

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

HEMATOLOGY VALUE REFERENCE

VALUE

UNIT

WBC 15,76 4,00-10,0 (10³/UI)

RBC 4,19 4,00-6,00 (106/UI)

HGB 12,4 12,0-16,0 (gr/dL)

HCT 34,6 37,0-48,0 (%)

PLT 241 150-400 (103/uL)

GDS 175 140 Mg/dL

Ureum 23 10-50 Mg/dL

Creatinin 0,9 <1,3 Mg/dL

SGOT 22 <38 mmol/L

SGPT 54 <41 Mg/dL

Total Cholesterol 200 200 Mg/dL

HDL Cholesterol 66 L(>55), P(>65) Mg/dL

LDL Cholesterol 109 <130 Mg/dL

Trygliceride 67 200 Mg/dL

CK 79 L(<190),P(<167) U/L

CKMB 42 <25 U/L

Troponin T 0,20 <0,05 ---

Natrium 119 136-145 mmol

Kalium 4,2 3,5-5,1 mmol

Chloride 94 97-111 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 sST 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 functionand movement - Pulmonal : good functionand movement

• E/A <1

Conclusion :• LV systolic and diastolic disfunction,

EF 30%• Dilatation of LV & LA • Global hypokinetic

CONGESTIVE HEART FAILURE NYHA III e.c.

CORONARY ARTERY DISEASE

• Bed rest• Oxygen 2-4 lpm via nasal canul• IVFD NaCl 0,9% 500 cc/24 hours• DiureticFurosemide 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

CONGESTIVE HEART FAILURE

Other Causes

Arrhythmias Valvular heart diseaseCongenital heart diseasePericardial diseaseHyperdynamic circulationAlcohol and drugs(chemotherapy)

Main Causes

Ischemic heart disease (35%-40%)Cardiomyopathy(dilated) (30-40%)Hypertension ( 15-20%)

Etiology of Heart Failure

Major Criteria Minor Criteria

Paroxysmal Nocturnal Dyspnea CardiomegalyGallop S3Hepatojugular refluxIncreased of JVPRales or ronchiAcute pulmonary edemaProlonged circulation time(> 25

sec)Weigh loss ≥ 4,5 kg in 5 days in response to treatment of CHF

Extremity edemaNocturnal coughDecreased vital

pulmonarycapacity (1/3 of maximal)HepatomegalyPleural effusionTachycardia (≥ 120bpm)Dyspnea d’effort

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.

Cardiac Biomarkers

Tissue Normal Value

Creatine Kinase (CK) Striated muscle, heart tissue, and brain

Male (52-336 U/L)Female (38-176 U/L)

Creatine Kinase Myocardiac Band (CK-MB)

Heart muscle, few in skeletal muscle

<6.2 ng/mL (0.3%)

Cardiac-specific Troponin T (cTnT)

Myofibrilar protein found in myocardium

<0.01 ng/mL (<0.01 µg/L)

Cardiac-specific Troponin I (cTnI)

Myofibrilar protein found in myocardium

<0.01 ng/mL (<0.01 µg/L)

Myoglobulin Myoglobulin found in heme protein in smooth and skeletal muscle

0.00-0.09 µg/L (0-90 µg/L)