CONGESTIVE HEART FAILURE (CHF) NYHA IV e.

c post Partum Cardiomyopathy (PPCM)

Supervisor :

By : Marhawa C 111 07007

Patient Identity
Name Gender Age Medical Record

Date of Admission
Address

: Ms. K : Female : 33 years old : 601710 : 30 Maret 2013 :Jl. Dg Tata , Mks

Anamnesis (1)
Chief Complaint : Shortness of breath Pasien MRS dengan rujukan dari RSUD Pangkep dengan D/ Post partum 8

hari+ efusi pleura+ Anemia. Ibu mengeluh sesak nafas sejak 1 minggu yang lalu ( 2 hari post partum)makin lama makin memberat, sesak dirasakan setiap saat, tidak dipengaruhi aktivitas. batuk (+), lendir (+) berwarna putih, darah (-), demam (+) Riwayat perdarahan dari jalan lahir (-) Riwayat diraawat di ICU Pangkep diberikan drips furosemid q amp dan inj. Widecillin Riwayat melahirkan normal di RS KDIA ST. Fatimah tanggal 14 Maret 2013 dengan BB lahir bayi 2800 gram Riw HT (-), DM (-), asma (-), alergi (-)

Pemeriksaan fisis KU : sesak. Anemis T 140/100 mmHg N : 140x/ menit P : 40x/menit S : 38,3 C Status lokalis Mammae : engorgement Thorax : VBS kanan menurunRhonki -/- ??? wheezing -/TFU : 2 jari atas SOP Fluxus (-) PDV : tidak dilakukan

Past Medical History

There is history of being admitted to the

hospital 2 times with the same complaint of shortness of breath. There is history of hypertension since 10 years ago but she doesnt take the drugs regularly. She never smoking and consumption alcohol. There is no history of fever, congenital heart disease, thyroid disease, and diabetes mellitus. There is also no family history with cardiovascular disease and thyroid disease.

Risk Factors
Cigarette smoking (-)

Alcohol consumption(-)
Hypertension(+) Diabetes Mellitus(-) Cardiovascular disease (+) Thyroid disease (-) History of cardiovascular disease and

thyroid disease in family (-)

Physical Examination
General Status: Severe ill Nutritional Status: Good Consciousness: Conscious Vital Signs: Blood Pressure : 120/70 mmHg Pulse Rate : 92 bpm, regular Respiratory Rate : 28 bpm Temperature : 36.7 C

Physical Examination
Head and Neck Examinations:
Eye

: Conjunctiva anemic (-/-), sclera icteric (-/-) Lip : 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 Auscultation Palpation

: flat, following breath movement : Peristaltic sound (+), normal : No mass, no tenderness, no palpable

liver and spleen

Percussion

: Tympani (+), ascites (-)

Extremities Examination
Pretibial edema -/-

Dorsum pedis edema -/-

Electrocardiography(ECG)
Interpretation:
Rhythm:No sinus HR/QRS

rate:75x/minutes Regularity: regular P wave & PR interval: 0,08s and 0,16 s QRS Complex: 2 small squares(0.08s), Q pathologies in V1,V2, V3. VES (+) Axis: Normal ST segment: Normal T wave: Normal

Conclusion of ECG
Sinus rhythm.

HR 75x/minutes.
Normoaxis. P wave normal. Q pathologies in V1, V2, and V3 (OMI

Anteroseptal). VES (+). T wave normal

Chest X-rays
Conclusion : Cardiomegaly (CTI (8+10)/ 32= 0.56) , pulmonary edema with dilatation and elongation aortae

Laboratory Finding
Complete Blood Count Test Result Normal value

WBC
RBC

7.9/ul
3.96/l

4.0 10.0 x 103

4.0 6.0 x 106

HGB
HCT PLT

11.6 gr/dl
36.0% 221 000/l

12 16
37 48 150 400 x 103

Electrolyte Test Na Result 149 mmol/l Normal value 136-145

K
Cl

4.1 mmol/l
117 mmol/l

3.5-5.1
97-111

Laboratory Finding
Blood Chemistry Test GDS Ureum Creatinine SGOT SGPT Total Chol HDL Chol LDL Chol TG Cardiac Enzymes Test CK CK-MB Troponin-T Result 64 U/L 9 U/L <0.1 Normal value <167 <25 Negative Result 131 mg/dl 70 mg/dl 1.0 mgr/dl 35 u/l 36 u/l 150 mg/dl 43 mg/dl 77 mg/dl 76 mg/dl Normal value <140 10 50 < 1.3 <38 <41 <200 > 55 < 130 <200

Diagnosis
CHF NYHA III e.c CAD (OMI

anteroseptal)

Management
O2 5 lpm IVFD NaCl 0.9% 10

Aspilet 80 mg 0-1-0 Captopril 12,5 mg

dpm
Inj. Furosemide 40

1-1-1
Alprazolam 0.5 mg

mg/12 jm/ IV
Fasorbid 10 mg 1-1-1

0-0-1

Planning
ECG control Echocardiography

DISCUSSION
Congestive Heart Failure (CHF)

Definition
Heart Failure
Heart is no longer able to pump an adequate supply of blood in relation to the venous return and in relation to the metabolic needs of the body tissues at the particular moment

Congestive Heart Failure

The state in which abnormal circulatory congestion occurs as the result of heart failure.

Etiology of Heart Failure

Main Causes Ischemic heart disease

(35%-40%)

Other Causes

Cardiomyopathy(dilated)
(30-40%)

Hypertension ( 15-20%)

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

Major Criteria
Paroxysmal Nocturnal Dyspnea Cardiomegaly

Minor Criteria
Extremity edema Nocturnal cough

Gallop S3
Hepatojugular reflux Increased of JVP Rales or ronchi Acute pulmonary edema Prolonged circulation time(> 25 sec) Weigh loss 4,5 kg in 5 days in

Decreased vital pulmonary

capacity (1/3 of maximal) Hepatomegaly Pleural effusion Tachycardia ( 120bpm) Dyspnea deffort

response to treatment of CHF

Classification of CHF

Pathophysiology of CHF
Plaque in coronary artery Blood flow to heart muscle is reduced. Heart muscle lacking of oxygen Ischemia of heart muscle can lead to myocardial infarction

Symptomatic Congestive Heart Failure

Pulmonary edema Abnormal Heart rhythm

The heart muscle cant pump adequately

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 Coronary Artery Disease

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
Risk Factors That Cannot Be Modified: Age and gender. As get older, risk for CAD increases. Men, risk increases after age 45. Women, risk increases after age 55 (or menopause). Family history of early heart disease. Heart disease diagnosed before age 55 in father or brother. Heart disease diagnosed before age 65 in mother or sister. Risk Factors That Can Be Modified: High blood cholesterol (hyperlipidemia) High blood pressure (hypertension) Cigarette smoking Diabetes Overweight or obesity Lack of physical activity

INVESTIGATION
Electrocardiogram (ECG)

Treadmill Test
Echocardiography Coronary Angiography Multi-Slice Computed Tomography Scan

(MSCT) Cardiac Magnetic Resonance Imaging (Cardiac MRI) Radionuclear Medicine

TREATMENT (1)
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 (2)
Special Procedures Angioplasty (PTCA) Coronary artery bypass surgery Enhanced External Counterpulsation (EECP) Cardiac Rehabilitation Exercise training Education, counseling, and training

Terima Kasih.

AriGato.

THANK YOU
Danke.

Gracias..

Matur Nuwun. Syukron.