CONGESTIVE HEART FAILURE

(CHF) NYHA IV e.c Coronary

Artery Disease (OMI
Supervisor :
Anteroseptal)

Prof. dr. Peter Kabo, Ph.D, Sp.FK, Sp.JP(K)

By :
Muhammad Adhim Alwi
C111 08 166

Patient Identity
Name
Gender
Age
Medical Record
Date of Admission
Address

: Mr. S
: Male
: 60 years old
: 362481
: 11 January 2015
: Jln. Flamboyan, MKS

Anamnesis
Chief Complaint: Shortness of breath
Shortness of breath has been experienced since

2 years ago and worsened 1 week ago. It was

experienced even the patient is at rest and
relieved with ist own. The patient also complains
chest pain which has been experienced since 7
years ago. Chest pain was felt on the left side of
the chest with the characteristics of heavy feeling
on the chest, duration of pain was < 5 minutes,
did not radiate to the left arm and to the back.

Anamnesis
The pain exacerbates with exercise and lessen
with rest. Dyspnea on effort (+), Orthopnea (-),
Paroxysmal Nocturnal Dyspnea (+), Cough (+)
intermittent since 1 year ago. Palpitation (+),
Fever (-) Nausea (-) Vomit (-). Defecation and
urination: normal.

Past Medical History

There is history of being admitted to the hospital 7

years ago with a diagnosis CAD and do installation

balloons and rings .
There is history of hypertension since 7 years ago
but he doesnt take the drugs regularly.
There is history of smoking since 35 years ago but
stopped 7 years ago.1 box per day.
There is no history of fever, congenital heart disease,
thyroid disease, and diabetes mellitus.
There is also no family history with cardiovascular
disease.

Risk Factors

Physical Examination
General Status:
Moderate illness/ Well nourished/ Conscious
Nutritional Status: Normal (BMI: kg/m)
Weight : 55 kg
BMI: 20.2 kg/m2
Height : 165 cm
Vital Signs:
Blood Pressure : 130/60 mmHg
Pulse Rate
: 80 bpm
Respiratory Rate
: 25 bpm
Temperature
: 36.7 0C

Physical Examination
Head and Neck Examinations:
Eye
Lip

: Conjunctiva anemic (-/-), sclera icteric (-/-)

: cyanosis (-)
Neck : No mass, no tenderness, JVP : R + 3 cmH2O

Chest Examination
Inspection : Symmetric left=right
Palpation : No mass, no tenderness, vocal fremitus left=right
Percussion : Sonor left = right, lung-liver border in ICS VI right

anterior
Auscultation: Breath sound
: vesicular
Additional sound : Ronchi
Wheezing -/-

+ +

Physical Examination
Cardiac Examination
Inspection : Ictus cordis was not visible
Palpation
: Ictus cordis was not palpable
Percussion :Right heart border in right parasternal
line, left heart border two fingers from left
midclavicular line ICS VI.
Auscultation :
Heart sound : S I/II regular, no gallop, no
additional sound

Physical Examination
Abdominal Examination
Inspection
: flat, following breath movement
Auscultation
: Peristaltic sound (+), normal
Palpation
: No mass, no tenderness, no
palpable liver and spleen
Percussion
: Tympani (+), ascites (-)
Extremities Examination
Pretibial edema -/ Dorsum pedis edema -/-

Electrocardiography(ECG)

Interpretation of ECG

Rhythm : Atrial fibrillation

HR / QRS rate : 80 bpm
Axis
: Normoaxis
Regularity
: Irregular
P wave
: Difficult to assess
PR interval
: Difficult to assess
QRS complex : 0.08 s (N: 0.06-0.11 s)
Q pathologies : V1, V2, V3
ST segment
: Difficult to assess
T wave : Difficult to assess
Conclusion : Atrial Fibrillation Normal Ventricular
Response, OMI anteroseptal

Echocardiography

Conclution of
Echocardiography
Systolic and diastolic dysfunction of the left ventricle

Ejection fraction 33%

Left ventricular hypertrophy
Trivial Mitral regurgitation
Thrombus in the left ventricle with a diameter 2.8 x 3.6
cm
Akinetik basal anteroseptal, mid anteroseptal and
anterior, apical anteroseptal, anterior, the other
segments hipokinetik

Chest X-rays

Conclusion :
Normal Pulmonary
Cardiomegaly with
dilatation aortae

Laboratory Finding
Complete Blood Count
Test

Result

Normal value

WBC

11.1/ul

4.0 10.0 x 103

RBC

5.61/l

4.0 6.0 x 106

HGB

16.7 gr/dl

14 18

HCT

49.1%

40 54

PLT

290 000/l

150 400 x 103

Electrolyte
Test

Result

Normal value

Na

146 mmol/l

136-145

4.5 mmol/l

3.5-5.1

Cl

113 mmol/l

97-111

Laboratory Finding
Blood Chemistry
Test

Result

Normal value

GDS

98 mg/dl

<140

Ureum

22 mg/dl

10 50

Creatinine

1.5 mgr/dl

< 1.3

SGOT

28 u/l

<38

SGPT

34 u/l

<41

Test

Result

Normal value

CK

77.7 U/L

<167

CK-MB

15.4 U/L

<25

Troponin-T

<0.02

<0.05

Cardiac Enzymes

Diagnosis
CHF NYHA IV e.c CAD (OMI

Anteroseptal)
Atrial Fibrillation Normal Ventricular
Response (AF NVR)

Management
O2 2-4 lpm via nasal canul
IVFD NaCl 0.9% 10 dpm
Fluid Balance
Inj. Furosemide 40 mg/12 hours/ IV
Fasorbid 10 mg 1-1-1
Aspilet 80 mg 0-1-0
Captopril 6,25 mg 1-1-1
Simvastatin 1 x 20mg
Digoxin 0.125 mg 1-0-0

Planning
ECG control

DISCUSSION
Congestive Heart
Failure (CHF)

DEFINITION

Etiology of
Heart Failure
Main Causes
Ischemic heart disease
(35%-40%)

Cardiomyopathy(dilated)
(30-40%)

Hypertension ( 15-20%)

Other Causes
Arrhythmias
Valvular heart disease
Congenital heart disease
Pericardial disease
Hyperdynamic circulation
Alcohol and
drugs(chemotherapy)

Major Criteria

Minor Criteria

Paroxysmal Nocturnal Dyspnea

Extremity edema

Cardiomegaly

Nocturnal cough

Gallop S3

Decreased vital pulmonary

Hepatojugular reflux

capacity (1/3 of maximal)

Increased of JVP

Hepatomegaly

Rales or ronchi

Pleural effusion

Acute pulmonary edema

Tachycardia ( 120bpm)
Dyspnea deffort

Classification of CHF

Pathophysiology of CHF

Treatment of CHF

Coronary Artery Disease

Coronary artery disease is a narrowing of the small blood

vessels that supply blood and oxygen to the heart.

(CAD) occurs when the arteries that supply blood to the
heart muscle (the coronary arteries) become hardened
and narrowed due to buildup of a material called plaque
(plaque) on their inner walls. This is known as
atherosclerosis
Eventually, blood flow to the heart muscle is reduced,
and, because blood carries much-needed oxygen, the
heart muscle is not able to receive the amount of oxygen
it needs.

Causes CAD
Coronary

artery disease (CAD) is caused by

atherosclerosis (the thickening and hardening of the
inside walls of arteries). Some hardening of the
arteries occurs normally as a person grows older.
In atherosclerosis, plaque deposits build up in the
arteries. Plaque is made up of fat, cholesterol,
calcium, and other substances from the blood.
Plaque buildup in the arteries often begins in
childhood.

Plaque in the arteries can be:

Hard and stable. Hard plaque causes the artery
walls to thicken and harden. This condition is
associated more with angina than with a heart
attack, but heart attacks frequently occur with hard
plaque.
Soft and unstable. Soft plaque is more likely to
break open or to break off from the artery walls and
cause blood clots. This can lead to a heart attack.

RISK FACTORS

INVESTIGATION
Electrocardiogram (ECG)
Treadmill Test
Echocardiography
Coronary Angiography
Multi-Slice Computed Tomography Scan (MSCT)
Cardiac Magnetic Resonance Imaging (Cardiac

MRI)
Radionuclear Medicine

TREATMENT
Lifestyle Changes
Eat a healthy diet
Quit smoking, if you
smoke
Exercise
Lose weight, if you are
overweight or obese
Reduce stress

Medicines
Cholesterol-lowering
medicines
Anticoagulants
Aspirin
ACE inhibitors
Beta blockers
Calcium channel
blockers
Nitroglycerin
Long-acting nitrates

TREATMENT
Special Procedures
Angioplasty (PTCA)
Coronary artery bypass surgery
Enhanced External Counterpulsation (EECP)
Cardiac Rehabilitation
Exercise training
Education, counseling, and training

THANKYOU