GRAND ROUND

1 / 8 /56 Ext. Patcharapol Udomluck

Identification data
53 . . . 14/7/56

Chief complaint
3

Present illness
3 ( 4-5 ) ( ) 5

Present illness

Past history
:
2549 AF and Ischemic heart disease CAG Echo 2550 RHD - Severe MS S/P PTMC ( 50) :

Past history
( ): ( )
2554 : Admit due to Hemoperitoneum Warfarin Admit CHF Echo 17 / 11 / 54
MV and AV Hockey stick appearance TV non Coaptation RA, RV, LA dilated, LV D-shape LVEF 69% Dx. RHD, Mod to sev MS, Mild MR, Severe TR RVSP 40 mmHg

Past history
( ): ( )
2555 : Admit due to Cardiac ascites Abdominal paracentasis : No Infect or Malignant 2549 2556 Warfarin INR 1.3 1.7
22 / 5 / 56 INR 1.8 Warfarin (3) 1 tab o hs (14 mg/wk)

Past history
22 / 5 / 56 :
Pen V (250) 1 tab O BID, ac Enarapril (5) tab O hs Furosemide (40) 1 tab O OD,pc Spironolactone (25) 1 tab O OD.pc Atenolol (50) 1 tab O OD,pc Folic (5) 1 tab O OD Vit Bco 1 tab O OD Omeprazole (20) 1 tab O OD.ac MOM 2 tsp O hs

Percutaneous Transluminal Mitral Commissurotomy

Family & Personal history

Family history Personal history

Physical examinations
Vital signs : BT 36.7 oC RR 28 / min HR 164 /min Totaly Irregular BP 110/60 mmHg General appearance : A Thai female patient , good consciousness ,no jaundice, no cyanosis, Looked dyspnea HEENT : mild pale conjunctiva, anicteric sclera, no dry lip and mucosa, no oral

Physical examinations
Cardiovascular :
Inspection : Active precordium, Neck vein engorge, +/- Corrigan sign Palpation : PMI at left 6th MidAxillar , LV Heave, Thrill, Totally Irregular full pulse, Not evaluate Pulsus paradoxus, Capillary refill < 2sec Auscultaiton : PSM Gr V at Lt Lower parasternal border radiate to neck and DRM Gr V at apex radiate to axillary , +/- Loud P2,

Physical examinations
Lungs : no chest wall deformity, Subcostal retraction, no spider nevi, trachea in midline, normal breath sound, normal resonance on percussion both lungs, crepitation both lungs, normal vocal resonance

Physical examinations
Abdomen : no abdominal paradox, no superficial vein dilatation, no surgical scar, distend abdomen, active bowel sound, soft, not tender, no guarding, liver can be palpated, liver span 8 cm, spleen cant be palpate, shifting dullness negative Extremities: Pitting edema 2+ Skin : No rash

Problem list
Progressive dyspnea with generalized edema U/D RHD, Mod to severe MS, Mild MR, Severe TR, AF

Differential diagnosis
CHF Etiology : AF with Valvular heart disease DDx Precipitating by Anemia / Infection / Uncontrolled disease

Investigation
CBC, BUN, Cr, Electrolyte Coagulogram CXR EKG Cardiac enzyme

Before admit (10/55)

CBC
RBC 3.83 x 10^3 /ul Hb 10.7 g/dl HCT 33.0 % MCV 86.4 fl MCH 28.1 pg MCHC 32.5 g/dl RDW 15.2 % Platelet 101,000 WBC 8.2 x 10^3 /ul Neutrophil 85.8 % Lymphocyte 6.9 % Monocyte 5.8 % Eosinophil 1.2 %

LAB
Coagulogram PT 25.5 sec INR 2.13 PTT 34.6 sec PTT ratio 1.3 Cardiac enzyme 17.00 Trop I CKMB 22.00 Trop I CKMB 0.02 ng/ml 1.70 ng/ml 0.08 ng/ml 1.40 ng/ml

Chemistry
BUN Creatinine Na K Cl CO2 18 mg/dL 0.98 mg/dL 135 mmol/L 4.8 mmol/L 104 mmol/L 19 mmol/L

Management
Lasix 40 mg IV stat Digoxin 0.25 mg IV stat Monitor EKG keep HR < 140 Restrict fluid < 1 L/day O2 cannular 4LPM Amiodarone 150 mg + 5% D/W 50 ml IV drip in 30 min then Amiodarone 600 mg + 5% D/W 500 ml IV drip rate 20 ml/hr Off Amiodarone If HR < 70/min Add

Progress
21.45 .
O : BP drop 89/43 mmHg HR 62 /min P : Off Amiodarone
Dobutamine (2:1) IV 8 microdrop/min keep BP > 90/60 Record V/S q 15-30 min

22.00
O : BP 70/40 mmHg HR 70 /min P : Dopamine (2:1) IV 10 microdrop/min titrate 5-30 microdrop/min keep BP> 90/60
Off Enarapril, aldactone,atenolol

Progress note (15-7-56)

S: O: BT 36.5 C PR 104 bpm irregular BP 97/63 mmHg RR 26 bpm Heart- Murmur Lung- fine crepitation both lung Abdomen- active bowel sound, mod disension Extremities- pitting

Dopa 15 udrop/min Dobu 8 udrop/min Set Cavafix / CXR

CVP 34 cmH2O

CVP q 4 hr keep 8-20 Lasix 80mg V then 40 mg q 12hr

Progress note (16-7-56)

S: O: BT 36.3 C PR 74 bpm irregular BP 91/49 mmHg RR 24 bpm Heart- Murmur Lung- fine crepitation both lung Extremities- pitting edema I/O 714/3,700 O2sat

Dopa 24 udrop/min Dobu 8 udrop/min CVP q 4 hr keep 8-20 Lasix 40 mg q 12hr

Progress note (16-7-56)

11.00 . BP drop 80/50 mmHg PR 140-150 EKG : Unstable VT with pulse Na 133 Ca 8.8 Trop I 0.02 CKMB 1.1 K 3.9 Mg 1.6 Amiodarone 150 mg V push Cl 100 PO4 8.8 Off Dopamine, EKG 12 CO2 24 PR 100-110 BP 90/60 EKG : Suspected NLBBB Electrolyte,Mg, TropI,CKMB Observe BP 102/63 PR 90-100 Add Warfarin (2) 1 tab Ohs

Progress note (17 19 / 7 /56)

S: O: V/S No fever BP 100110/80-90 mmHg I/O Negative balance 1-2L Lung Fine crepitation CVP 23-29 cmH2O INR 1.72

Digoxin tab O OD,pc Echo

Progress note (21-7-56)

S: O: BT 37 C PR 108 bpm irregular BP 102/62 mmHg RR 22 bpm Heart- Murmur HEENT : Bleed per Orophalynx Lung- fine crepitation both lung

Observe bleed and Hct q 8 hr Vit K 10 mg IV Plt conc 4 U FFP 4 U Transamine 1 amp V q 8hr Off Warfarin Hct drop 33 28 PRC 1 U

OUTLINE
CHF Cardiogenic shock Valvular heart Warfarin

Stage A

Stage B

A High risk for Heart failure

implantable cardioverterdefibrillator

Stage C

Stage D

Heart failure

Preserve

Reduced

Mechanical Circulatory Suppor

cardiac resynchronization therapy Implantable Cardioverter-Defibrillator

Health-related QOL

Cardiogenic shock

The definition of cardiogenic shock

1. Persistent hypotension (1hr.) with unresponsive to fluid resuscitation
SBP < 80 - 90 mmHg or MAP 30 mm Hg lower than baseline

2. Cardiac dysfunction 3. Systemic hypoperfusion

a) severe reduction in cardiac index (CI)
CI < 1.8 ( L/min)/m2 without support or CI < 2.0 - 2.2 (L/min)/m2 with support

a) adequate or elevated filling pressure

left ventricular [LV] end-diastolic pressure>18 mmHg right ventricular [RV] end-diastolic pressure >10 -15 mm Hg

Management
1. 2. 3. 4. General supportive therapy A B C Inotropic and vasopressor agents Mechanical support Reperfusion therapy
Goal : Maintenance of adequate preload Decreased afterload Early reperfusion

Mechanical support (IABP)

Condition that should get IABP
Low cardiac output Hypotension Cardiogenic shock which failed treat by inotrope drug Before Surgical operation in AMI with severe mitral regurgitation or Ventricular septal rupture Right ventricular infarction which failed treat by IV supplement and inotrope drug

Valvular heart disease

Severe TR Severe MR

Warfarin management

Warfarin management
Non-urgency or Bleeding risk
Start 3 mg/day - Goal INR in 5-7 day

Urgency
Start 3 mg/day with Heparin then stop heparin when INR in therapeutic range x2 day

Follow up
First week after start : INR every day Second and third week : 3 times/wk If Stable INR - Repeat every 4 Wk Unstable INR - Repeat every 2 Wk

Warfarin management
Recommend for Out of Goal INR
Search the Cause Change dose 5-20% of last dose (mg/wk) INR < 1.5 Raise up 10-20 % of last dose (mg/wk) Avoid VitK when Heigh INR and no bleeding If INR Heigh and severe bleeding
Give VitK 10 mg IV slowly push and FFP or prothrombin complex concentrate - then consider repeat vitK q 12 hr