Problem Based Learning

Cardiovascular System
2nd Group
2nd Group Members
• Bahtiar Nawabig H (6130014007)
• Andriani Agustin (6130014002)
• Rahmaniah Ulfah (6130014027)
• Andriani Agustin (6130014002)
• Bahtiar Nawabig H (6130014007)
• Claudia Narinda Rahma Putri (6130014012)
• Hessty Rochendah Onjiah (6130014017)
• Anydhia Fitriana Afiuddin (6130014022)
• Rahmaniah Ulfah (6130014027)
• Maya Ayu Elfrida (6130014032)
• Laila Al Istighfara (6130014037)
• Lintan Kurnia Farizqi (6130014042)
• Aprina Trimurtiningrum (6130014047)
SCENARIO
A man - 50 years old boy came to the hospital emergency room with shortness. In
heteroanamnesis obtained tightness felt since 1 month and increasingly heavy, especially
when do the activity. Claustrophobic feel improved when the sitting position. In addition,
patients also complained for a cough that felt since 6 months but the patient refused to
see a doctor. 1 year ago the patient was diagnosed with pulmonary tuberculosis, but
stopped the treatment for two months because it was already improving.
Physical examination:
RR 36 / min (cusmoul / breath and quickly), t 37.9˚C, BP ​90/60 mm Hg (pulsus paradoxus),
BMI obesity.
Head / neck: Prominent JVP
Ictus cardiac intangible, Ronchi (-), wheezing (-), Symmetrical, heart sound  away.
Laboratory examination:
Within normal limits
Radiological examination:
X-ray: Enlargement of the heart (water bottle heart), pulmonary edema (-)
ECG:
Sinus tachycardia low voltage
echocardiography:
Pericard massive effusions, fibrin network systolic function is still good
 Laboratorium
Chest X-ray
Obtained cardiomegaly, heart shapes, globular,
such as bottled water or contained calcifications
pericardium. Pleural effusion can be seen at
1/3 pasien.
thoracic CT-scan
Will show the changes pleural thickening
and irregularities perikardium.
Electrocardiography
12 lead ECG, may show: sinus tachycardia,
low voltage on QRS waves, electrical
alternans (change in voltage QRS complex
with a ratio of 2: 1, as a result of cardiac motion
on pericardial space) and the segment depression
PR.
Echocardiography
Accurate examination for the diagnosis of
tamponade cardiac and pericardial effusion;
could
whether there is a pericardial effusion or
fibrin and estimate the amount of liquid
pericardial effusion.
The picture can be found:
- Late diastolic collapse of the right atrium
- Heart swaying (swinging heart) in
the pericardial space.
- Pseudohypertrophy left ventricle.
- The decline of more than 25% of mitral valve
flow.
- Nuclear imaging
67 Gallium and indium-111 has been used
to diagnose TB pericardial effusion though
the result is not spesifik.
Keywords
• Complaints tightness and coughing with a history of
pulmonary tuberculosis.
•RR 36 breaths / min (Kusmaul / breath and quickly)
•T: 37.9˚C
•Tension: 90/60 mmHg (pulsus paradoxus)
•BMI: obesity
•Head / neck: Prominent JVP
•Symmetrical, heart sound away.
• X-ray: Enlargement of the heart (water bottle heart),
pulmonary edema (-)
• Sinus tachycardia low voltage
•EKG: pericard massive effusions, fibrin network systolic
function is still good
Learning Objective
1. Being able to know the anatomy of the thoracic cavity,
mediastinum, heart, and lungs.
2. Being able to know the etiology, pathophysiology, pathogenesis,
clinical manifestations, as well as the governance of DD among others:
- Heart failure
- Pulmonary Tuberculosis
- Pleural effusion
- effusion pericard (tamponade)
- pericarditis
3. Being able to know gamabaran radiology, ECG, and
echocardiography at:
- Heart failure
- pericarditis
- tamponade
4. Able to determine the relationship pericard effusion (tamponade)
with pulmonary tuberculosis.
MIND MAPPING
Mind Mapping

TB LUNG INFECTION

TREATMENT Inadequate

LIMFOGEN HEMATOGEN

MIGRATION TO
pericardium

Without PERIKARDITIS TB
pulmonary TB
infection

St. fibrinosa St. Efusi Absorbsi Efusi Thickening of the

pericardium Parietal

EFUSI PERIKARDIUM

(TEMPONADE )
Thoracic Cavity
Mediastinum
Heart
Pericardium
Pulmo and Pleura
HEART FAILURE
Etiologi
 coronary heart disease 60-75%, with the cause of 75% of
hypertensive heart disease
 valvular disease (10%) as well as cardiomyopathy and other
causes (10%)
 Risk factors such as diabetes and smoking weight and height
ratio of total cholesterol
Clinical Manifestations Assesement
SYMPTOM SIGN 1. General Therapy and Lifestyle Factors
Topikal Spesifik
 dispneu  Increased JVP a. Physical activity should be adjusted to the level of
symptoms.
 Ortopneu  Refluks hepatojugular
b. Oxygen is the lung vasorelaxant, an RV afterload, and
 Paroxysmal nocturnal  S3 heart sounds (gallops) improve pulmonary blood flow.
 Dyspnoe c. Smoking tends to decrease cardiac output, increase
 Tolerance activity  Apex shifted to the heart heart rate, increased systemic vascular resistance and
diminish lateral pulmonary and must be stopped.

 get tired  heart murmur

2. Drug therapy
 Swelling in the wrist leg
Less typical Less typical
a. Diuretics are used in all circumstances in which the
 Cough at night / early morning  Edema perifer desired increase in expenditure of water, especially in
 wheezing  Krepitasi pulmonal hypertension and heart failure
 Weight gain> 2 kg / week  Sounds dull in the lung bases on b. William Withering of Birmingham found the use of
percussion extracts of foxglove (Digitalis purpurea)
c. Vasodilators can reduce cardiac afterload and
 Weight down (failed advanced  Takikardia
ventricular wall stress, which is a major determinant
heart) of oxygen needs moikard, decrease myocardial
 A feeling of bloating / fullness  irregular pulse oxygen consumption and increase cardiac output
 Decreased appetite  rapid breathing d. Beta Blockers (carvedilol, bisoprolol, metoprolol).
 discomfiture (Especially  Heaptomegali Beta-adrenoceptor blockers in heart failure are
patients aged usually avoided because of its negative inotropic
work.
continued)
e. Antikoagolan are substances that can prevent blood
 Flutter  Asites
clotting by inhibiting the formation of fibrin.
 Fainting  Kaheksia
f. Antiarrhythmics can prevent or eliminate the
interference by normalizing the frequency and
rhythm of the heart punch
Electrocardiogram (EKG)
ECG abnormalities have little predictive value in
diagnosing heart failure, if the ECG is normal,
the diagnosis of heart failure with systolic
dysfunction, especially very small (<10%)
(PERKI, 2015).
Echocardiography
Confirmation of Diagnosis must meet three
the diagnosis of heart criteria:
failure and / or cardiac 1. There are signs and / or
dysfunction by
echocardiography is a symptoms of heart failure
necessity and carried 2. The left ventricular systolic
out as soon as function is normal or only
possible in patients slightly impaired (ejection
with suspected heart fraction> 45-50%)
failure. Measurements 3. There is evidence of
of ventricular function
to distinguish diastolic dysfunction
between patients with (abnormal left ventricular
systolic dysfunction in relaxation / diastolic
patients with normal stiffness)
systolic function is the
left ventricular
ejection fraction
Radiology
• Increased vascular pattern and
blurred
• Looks inhomogen in both
pulmonary
• opacities, mainly in dextra
• Sinus costofrenicus dextra blunt
CTR> 0.5
• Looks calcification in the aortic
arch
• Cardiomegaly
• pulmonary edema
• Bilateral bronchopneumonia,
dextra more
• Pleural effusion dextra
• Aortasklerosis
TUBERCULOSIS
 TB

Definition Etiology
• Tuberculosis is an infectious • The cause of pulmonary
disease caused by bacteria tuberculosis is
Mikobakterium tuberculosis Mycobacterium
tuberculosis, rod-shaped
DIAGNOSE ! and have special properties
that is resistant to the acid
A positive TB skin test or TB blood test only
tells that a person has been infected staining.
with TB bacteria. It does not tell whether the
person has latent TB infection (LTBI) or has
progressed to TB disease. Other tests, such as
a chest x-ray and a sample of sputum, are
needed to see whether the person
has TB disease
Symptoms

• Coughing that lasts three or more weeks

• Coughing up blood
• Chest pain, or pain with breathing or coughing
• Unintentional weight loss
• Fatigue
• Fever
• Night sweats
• Chills
• Loss of appetite
Therapy

Drug therapy for initial empiric treatment of TB, start

patients on a 4-drug regimen: isoniazid, rifampin,
pyrazinamide, and either ethambutol or
streptomycin. Once the TB isolate is known to be
fully susceptible, ethambutol (or streptomycin, if it is
used as a fourth drug) can be discontinued.
Pleural Efussion
Pleural Efussion
Pleural effusion is the
accumulation of fluid in the ETIOLOGY
pleural cavity, where the fluid Pleural effusion can be
can be either exudate or the caused by:
transudate liquid •congestive heart failure
•pneumonia
•Malignancy
•pulmonary embolism
•Inflammation
•Trauma
•tuberculosis
PATHOGENESIS
The occurrence of pleural effusion caused by
an imbalance of hydrostatic pressure,
oncotic pressure in the blood vessels in the
parietal and visceral. Lymphatic drainage
capability which may cause a lot of fluid in
the pleural cavity.
It can be contain some pus. And it can be
hematotoraks if that process is in blood
vessels.
PATHOPHYSIOLOGY
• In inflammation, capillary
permeability of blood vessels
increases  mesothelium turn into
a round or cuboidal. It makes fluid
into the pleural space
• In heart failure, pleural effusion
may occur due to increased
hydrostatic pressure of the blood
vessels in systemic or pulmonary
circulation
• In trauma or malignancy of the
lymphatic drainage capability is
reduced  causing pleural effusion
 amount of fluid in the lungs
causing shortness of breath to
chest pain
CLINICAL MANIFESTATIONS THE MANAGEMENT OF PLEURAL
EFFUSION
• Dyspneu
• Pleurodesis
• Pain chest
• Cure the cause of disease
• Hacking Cough
• Antibiotic
• Fever (if patient has
• Torakosentesis therapeutic
inflmation)
Pericard Efussion/ Tamponade
 Pathophysiology Clinical Manifestation
• the growth of abnormal cells in the heart muscle   Acute cardiac tamponade:
uncontrolled cell hyperplasia  forming a mass
- Increased jugular venous pressure
(tumor)  pericardial space recessive  pericardial
friction with pericardium  pericarditis 
- Pulsus paradoxus> 10 mm Hg,
accumulation of fluid in the pericardium  - Pulse pressure <30mmHg
cardiac tamponade.
- Systolic blood pressure <100mmHg
• uremia  there are toxic metabolic blood
- Weakened heart sound
inflammation of the pericardium.

• Trauma blunt / penetrating  the pericardial space 

bleeding so much blood collected in the pericardial  Chronic cardiac tamponade:
space  heart driven by accumulation of fluid 
- The jugular venous pressure
cardiac tamponade
- tachycardia

- Pulsus paradoxus
Diagnostic and Management
• Photos thorax  enlarged
heart
• ECG electrical  alternas or P
and QRS wave amplitude
decreased in each subsequent
wave
• Echocardiography  pleural
effusion

Perikardiosintesis therapy
Electrocardiography (ECG)

12 lead ECG, may

show: sinus
tachycardia at low
voltage QRS wave,
electrica alternans
(QRS complex voltage
changes by a ratio of
2: 1, due to cardiac
motion at pericardial
cavity) and the
depression of PR
segment
Ecocardiography
Accurate examination for
the diagnosis of cardiac
tamponade or pericardial
effusion.
The picture can be found:
Late diastolic collapse of
the right atrium
Heart swaying (swinging
heart) pericardial cavity.
Pseudohypertrophy left
ventricle.
The decrease of more
than 25% of mitral valve
PERICARDITS
Etiology
 Bacterial, viral and fungal
 Injury heart
 Uremia
 Autoimmune diseases, such as
systemic lupus erythematosus
 Neoplasms
 Radiation therapy
 Certain drugs, hydralazine, etc.
 Aortic Aneurysms
 Myxoedema
Symptoms and signs
 Pericardial friction rub
 Sharp pain
 Shallow Breathing and fast
 Fever
 Dyspnoea, orthopnea,
tachycardia and signs of heart
failure
 Heart sound was distant and faint
 Pale, clammy skin, pulse
paradoxus, distended neck veins
 Fluid retention, ascites,
hepatomegaly,
 The sound of the pericardium in
early diastole
 Kusmaul Symptoms, distention v.
jugular
Pathophysiology
The process of inflammation and
infections secondary to the
phenomena of pericarditis will give a
response such as:
1. The occurrence of vasodilation with
increased accumulation of fluid into
the pockets of the pericardium.
2. Increased vascular permeability so
that the content of proteins,
including fibrinogen or fibrin, in the
liquid will increase.
3. Increased migration of leukocytes,
especially pericarditis purulent.
4. Bleeding from penetrating trauma
is also a possible cause.
The formation of scar tissue and
adhesions accompanied classification
visceral or parietal pericardium layer
leads to a constrictive pericarditis.
Accumulation of fluid in the
pericardium secretion exceeding
absorption causes a pericardial
effusion. Intra perikardial fluid
collection in an amount sufficient to
cause serious obstruction to entry of
blood into the chambers of the heart
can cause cardiac tamponade
Diagnosis Management
- Clinical History  Bedrest
- Physical examination  Handling underlying
- Electrocardiography cause
- Echocardiography  NSAIDs
- Laboratory tests  Antimicrobial if
there is an infection
 Corticosteroids
 Perikardiosentesis
 Perikardektomi
Radiology
• Effusion pericardium only slightly,
water bottle. At the pericardium
effusion, chest X-ray picture
shows a heart-shaped shadow
configuration jar of water but can
also be normal or nearly normal.
• In standing or sitting position, it
will appear enlarged heart
triangular and will be
transformed into globular in a
sleeping position.
• The amount of fluid there and big
heart that can actually be
predicted with angiokardiogram
or echocardiogram
 Electrocardiography (ECG)
Tachycardia, low QRS wave, concave ST segment
elevation, and electrical alternans. If the QRS
complex is affected, any other voltage QRS
complexes are smaller, often with reverse
polarity.
Echocardiography

Echocardiography is a
non-invasive
examination of the
most accurate. Would
seem accumulation of
fluid in the pericardial
cavity
Radiology
• Looks enlarged cardiac silhouette
with a clean picture of the lung
• Shows images of the "water
bottle heart-shape", if the liquid
over 250ml. Pericardial
calcification often encountered
pleural effusion.
Relationship pericardial effusion (tamponade)
with pulmonary tuberculosis
• Tuberculosis usually affects the lungs, but can also affect
other parts of the body. When TB occurs outside of the
lungs, the symptoms can vary accordingly. Without
treatment, TB can spread to other parts of the body
through the bloodstream :
– TB infecting the bones can lead to spinal pain and joint
destruction
– TB infecting the brain can cause meningitis
– TB infecting the liver and kidneys can impair their waste
filtration functions and lead to blood in the urine
– TB infecting the heart can impair the heart's ability to
pump blood, resulting in a condition called cardiac
tamponade that can be fatal.
Spodick DH. Tuberculous pericarditis. Arch Intern
Med. 1956; 98: 737–749.
• Pericardial involvement usually develops by
retrograde lymphatic spread of M tuberculosisfrom
peritracheal, peribronchial, or mediastinal lymph
nodes or by hematogenous spread from primary
tuberculous infection.
Tirilomis T, Univerdorben S, von der Emde J. Pericardectomy for
chronic constrictive pericarditis: risks and outcome. Eur J
Cardiothorac Surg. 1994; 8: 487–492
Four pathological stages of tuberculous pericarditis are recognized:
(1) fibrinous exudation with initial polymorphonuclear leukocytosis,
relatively abundant mycobacteria, and early granuloma formation
with loose organization of macrophages and T cells;
(2) serosanguineous effusion with a predominantly lymphocytic
exudate with monocytes and foam cells;
(3) absorption of effusion with organization of granulomatous
caseation and pericardial thickening caused by fibrin, collagenosis,
and ultimately, fibrosis; and
(4) constrictive scarring: the fibrosing visceral and parietal
pericardium contracts on the cardiac chambers and may become
calcified, encasing the heart in a fibrocalcific skin that impedes
diastolic filling and causes the classic syndrome of constrictive
pericarditis.
• The three principal features of tamponade (Beck’s
triad) are hypotension, soft or absent heart sounds,
and jugular venous distention with a prominent x
descent but an absent y descent.
Management

• Anti-tuberculous treatment
• Corticosteroids
• Drain effusion Pericardiocentesis vs Surgical
drainage
Corticosteroids in TB Pericarditis

• Strang JI, et al. Lancet. 1988; 332(8614):759-64

– Prednisolone vs placebo x11 weeks with RIPE
Randomized, prospective
Conclussion
Pericardium infected either haematogenously, limfogen
or pericarditis TB induces a delayed hypersensitive response
and stimulate lymphocytes to release lymphokines that
activate macrophages and affect the formation of
granulomas in the pericardium, causing the abnormal
accumulation of fluid perikardiun which may result effusion
pericardium and the resulting decline in output cardiac and
hypotension (tamponade). Cardiac tamponade is one of the
complications that must be overcome because it can be fatal.
Echocardiography is the diagnostic tool of choice and
sensitive for the diagnosis of pericardial effusion and cardiac
tamponade. Management of cardiac tamponade due to TB
pericarditis include providing antituberculosis drugs,
corticosteroids, and perikardiektomi perikardiosentesis.
THANK YOU