Congestive Heart Failure

Ivan Virnanda Amu

Pendrik Tandean

I N T R O D U C T I O N(1)
Heart failure is the inability of the heart to maintain cardiac
output to support metabolic demands of the body.
The decrease in cardiac output resulting in reduced effective
blood volume.

Clinical manifestations of
heart failure consists of
various hemodynamic
response, renal, neural, and
hormonal abnormalities.

Reflex of homeostasis/compensation
mechanism :
Neurohormonal changes
Ventricular dilatation
Frank-Starling mechanism.

I N T R O D U C T I O N(2)

20 million people
The prevalence of heart failure in the
adult population in developed countries is
2%.
The prevalence of heart failure : increases
with age, and occurs in 6-10% of parents
at the age of 65 years.
Incidence of heart failure was lower in
women than in men
The overall prevalence of heart failure is
expected to increase

Anamnesis
Mr. M, Men, 61 y.o, admitted to ER (Januari 22nd, 2014) with chief complain
shothness of breath, since 1 week ago and worsening 1 day ago, intermittent,
DOE (+), PND (+). patients feel claustrophobic if the move where previously
activity is never compromised patients, patients slept with 2 pillows. During
the last month patient feel tired easily, always feel weak, and spent a longer
time to rest so that productivity decreases.

Occasionally cough, dry cough, no fever, there is no history of fever.

No chest pain, there is history of chest pain approximately 4 months ago, with pressedlike sensation on centre of chest, radiated to left arm, with cold sweating, It felt more
than 1-2 minutes.

Date Here

Anamnesis (2)
Micturation and defecation normal, as usual.
There is history of Coronary Disease since 4 months ago,
but the patient did not take a medicine and go to the
doctor.
History of Hypertension since 3 years ago, but the patients
didnt take medicine regularly
History of Smoking, one pack daily.
History of DM (-)

Physical Examination

(1)

General Status Moderate ill/Well nourish/conscious.

Vital status : BP 140/80 mmHg, pulse 105 beats / min, regular, RR 28 /
min, temperature 36.7 C axiller, Weight 50 kg, Height 163 cm,BMI
21.67
Head and Neck
Anemia (-), Icteric (-), cyanosis (-). No lymph nodes enlargement. No
deviation of the trachea and Jugular Venous Pressure R +3 cmH20

Thorax
Lung
Inspection : looks symmetrical, does not seem respiratory lag,
Palpation : No tumor mass, between the ribs is not widened, tactile
fremitus normal, resonant percussion. Vesicular breath sounds on
auscultation, Rales : both of lung bases.
Cardiac
Inspection ictus cordis does not appear and was not palpable, Normal
Impression of heart border, Heart Sound I / II regular, Murmur (-)

Physical Examination(2)
Abdominal
Insp : Ascites -/Palp : Liver and spleen : No enlargement.
Perc : Tympani.
Ausc : Peristaltic Normal.
Extremity
Edema -/Warm acral

Laboratory Exam
WBC

7,5 103/mm3

Eritrosit

5.15 106 /mm3

Hb

16,0 g/dl

HCT

46,6 %

MCV

97 m3

MCH

31,1 pg

MCHC

32,2 g/dl

RDW

15,2 %

PLT

182 103/mm3

MPV

7,7 m3

NEU

61,4 %

LYM

26,4 %

MON

5,7 %

EOS

3,3 %

BAS

3,2 %

Total Cholesterol
LDL
HDL
TG
CK
CKMB
Troponin T
Uric Acid
HbsAg
PT
INR
aPTT
GDS
Ureum
Creatinine
SGOT
SGPT
Natrium
Kalium
Chlorida

167 mg/dl
27 mg/dl
140 mg/dl
85 mg/dl
121 U/L
16 U/L
< 0,002
9,4 mg/dl
Reaktif
12,7 control 10,0
1,09
34,9 control 23,7
112 mg/dl
40 mg/dl
1,3 mg/dl
21 U/L
18 U/L
145 mmol/l
3,6 mmol/l
115 mmol/l

ECG

Sinus Rhytm, HR 103x/m, Axis +170 , P wave 0,08 s, QRS complex 0,08 s, PR Interval 0,16 s, QS Configuration V1V4,
Conclussion : Sinus Tachycardia, RAD, OMI Anteroseptal

Chest Radiology
Dilatation of hillus,
parahillar, and suprahillar
both of lung
No spesific both of lung
Cor : CTI 0,57 aorta
dilatation
Normal Sinus and
diaphragm
Intact bone
Conclussion :
Cardiomegaly with
pulmonary congestion.
Aorta dilatation

Echocardiography
Conclussion :
Sistolic and Diastolic
dysfunction LV, EF 29 %
Dilatation of LA and LV
Anterior akinetic
anterior, anteroseptal.
Hipokinetic in the other
segment
MR severe
AR trivial

Working Diagnosis
CHF Nyha III ec CAD
Hyperuricemia
HBV

M
A
N
A
G
E
M
E
N
T

Oxygen 2-3 Lpm via nasal canula

NaCl 0,9 % 500 cc/24 hours/IV
Lasix 40 mg/12 hours/IV
Aspillet 1x 80 mg
ISDN 3 x 10 mg
Captoril 2x12,5 mg
Simvastatin 1x20 mg
Allopurinol 1x300 mg

DISCUSSION

ThemeGallery
is a
Systolic heart
failure is the
Design
Digital
inability of the
heart
to Content
pump &
mall of
developed
so that the Contents
contraction
the
by Guild Design Inc.
heart
decreases
and
weakness,
fatigue,
and
decreased physical activity
abilities and other symptoms
of hypoperfusion.

Diastolic heart failure is a

disorder of impaired relaxation
and ventricular filling. Diastolic
heart failure is defined as heart
failure with an ejection fraction
of more than 50 %.

ETIOLOGY
Myocardial disease

Mechanical disturbance in myocardial

infarction alone so there is actually no
abnormalities.

Coronary heart disease (ischemic heart

disease)
Cardiomyopathy
Myocarditis and rheumatic heart
disease
Infiltrative disease
Iatrogenic due to drugs or as a result of
radiation

Pressure
overload,
such
as
hypertension, aortic stenosis, aortic
coartasio.
Volume Overloaded, such as aortic or
mitral insufficiency, congenital heart
disease (left to right shunt) or
excessive transfusion.
Barriers charging, such as constrictive
pericarditis or tamponade.

PATHOPHYSIOLOGY

Pulmonary symptoms include: dyspnoea,

paroxysmal nocturnal dyspnea and orthopneu.
Additionally nonproductive cough that arise at
the time of lay

SIGN AND
SYMPTOMS

Systemic signs and symptoms such as weakness,

rapid fatigue, oliguria, nausea, vomiting, increased
central venous insistence, tachycardia, narrow
pulse pressure, ascites, hepatomegaly, and
peripheral edema

Nervous system symptoms such as : insomnia,

headaches, nightmares until delirium

FRAMINGHAMS CRITERIA
MAJOR

Paroxysmal nocturnal dyspnea

Neck vein distention
Pulmonary Crackles
Cardiomegaly
Acute pulmonary edema
S3 Gallop
Elevation of jugular venous
Hepatojuguler Reflex

MINOR

Extremity edema
Nocturnal cough
Dyspnea d' effort
Hepatomegaly
Pleural effusion
Decrease in vital capacity 1/3 of the normal
Tachycardia ( > 120 beats / min)
Major or minorWeight loss 4.5 kg in 5 days of
treatment. Diagnosis of heart failure confirmed at
least 1 major criteria and 2 minor criteria

ACUTE CHF

Lab finding
increase RBC
decrease in PO2
Acidosis on blood gas analysis

ECG :
tachycardia ( except those already treated ).
ischemic
impaired ventricular conduction function,
left bundle - branch block ( LBBB ),
changes in the ST segment and T wave

Sign :
Typical symptoms of pulmonary edema : dyspnea,
orthopnea, tachypnea, cough with frothy sputum,
sometimes hemoptysis.
Output of symptoms : tachycardia, hypotension and
oliguria
Angina pectoris on myocardial infarction .
Impaired left ventricular function are severe , it can be
found pulsus alternans.
Cardiogenic shock

Third heart sound (diastolic gallop).

Murmur sound in case of ventricular
dilatation.
Crackles wet

Chest X-Ray
Cardiomegaly, signs of lung dam
Pleural Effusion

American College of Cardiology / American Heart

Association 2005 Guidelines Update (4 levels severity)
A
Patients at risk of suffering from heart failure but no signs of heart failure, for
example patients with CHD, diabetes, cardiomyopathy and hypertension.

Patients suffering from structural heart disease. But there is no sign

of heart failure eg myocardial infarction, LVH or valvular heart
disease

Patients suffering from Structural Heart Disease and

symptoms of heart failure
Refractory heart failure despite maximal therapy. In this group
it is necessary for specific intervention such as a heart
transplant, permanent mechanical support.

MANAGEMENT

ACUTE
CHF

Overcome heart failure

syndrome
Increasing the
cardiac output

Decrease
ventricular filling
pressure

MANAGEMENT CHRONIC CHF

1 . Lowering preload. (Diuretic and Nitrat)

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2 . Increase cardiac contractility (for which an
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interruption of myocardial contractility). (Digitalis,
Ibopamin, -Blocker, Inhibitor Fosfodiesterase,
Isoniazide)Click to add Title

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3 . Lowering afterload (ACE Inhibitor, Angiotensin
Receptor Blocker, Direct Renin Inhibitor, Calcium
Channel Blocker, Adrenoceptor -1 Blocker

MANAGEMENT CHRONIC CHF

4. Prevent myocardial remodeling and inhibit the
progression of heart failure (ACE Inhibitor, ARB)

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Titlemetabolism with
5. Fixing myocardial
energy
carnitine, Co - enzyme Q10, D - ribose, magnesium
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and vitamins.
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6. Nonpharmacologic interventions aimed specifically for stage D of heart

failure patients who have not responded to medication. The specific
interventions can be Implantable Defibrillators Caardioverter (ICD),
Boventricular Pacing Theraphy, revascularization by PTCA or CABG 's, heart
transplantation, and ventricular reduction cardioplasti .

HEART FAILURE with Normal Systolic

Function
Increased in parallel with age
Mainly found in women
Symptoms : decrease in exercise capacity,
neurohormonal activation and decreased
quality of life.
Specific treatment against heart failure with
normal systolic function does not exist.
D-ribose, L-carnitine and Co-enzyme Q10
reported to improve output