Post partum cardiomyopathypptx

Grand Round Case Presentation
December 28th ,2022
1

NO NAME DIAGNOSIS
1. Mr ZM/ 62 yo APS CCS II ec susp IHD pro PAC standby PCI
HHD
DMT2
HBsAg positive
2. Mr NC/ 33 yo CHF FC NYHA II ec IHD (26%) pro PCI
CAD2VD CTO LCX (20/9/22)
HT
dislipidemia
3. Mrs S/ 73 yo ASD II, L to R shunt 19-24 mm, high flow low resistence
paroxysmal tachycardia
supraventricular tachycardia undocumented
TR moderate
High probability for PH
AF NVR
4. Mrs SA/ 47 yo ASD II L to R shunt
High Flow, Low Resistance
5. Mr AS/ 45 yo CHF FC NYHA II ec CAD3VD, CTO di LCx
PCI 4 DES di RCA (26/12/2022) incomplete revasc
DMT2
6. Mr WS/ 81 yo APS CCS II ec IHD pro PAC standby PCI
BPH
Asymptomatic bradycardia
Hiponatremia (Na 132)
VIP WARD

NO NAME DIAGNOSIS
1. Mr WE/60 yo CHF FC NYHA II ec IHD
HT stage II
AF NVR
2. Mr BS/79 yo CHF NYHA II ec CAD3VD CTO LCx (incomplete revasc)
Post PCI 1 DES proximal-distal LCX & 1 DES proximal-mid LAD (26/12/22)
HT
DM
3. Mr B/57 yo APS CCS II ec CAD3VD, diffuse disease, CTO di LAD & LCx
4. Mr M/33 yo CHF FC NYHA II ec Severe Mitral Regurgitation
Moderate TR
5. Mrs NF/26 yo ASD II Left to Right Shunt, Normal Flow High Resistance, Reactive Oxygen Test
TR severe
PR moderate
6. Ms HR/27 yo VSD perimembranous 13 – 14 mm , Left to right shunt
PS severe
RPO WARD

NO NAME DIAGNOSIS
1. Mr. AK/33 yo Acute STEMI anterior extensive onset 7 jam KILLIP I TIMI 2/14
Post PPCI 2 DES LAD pada CAD1VD (22/12/22) complete revasc
HT
Hiperurisemia (7.3) 23/12/22
6. Mr ZA/49 yo Acute STEMI Anterior onset 2 jam KILLIP 1 TIMI 3/14
Post PPCI 1 DES di LAD berhasil baik pada CAD3VD dengan STO di LAD (trombus type) dan CTO di RCA (imcomplet revasc)
22/12/22
DM tipe II
Hipertensi grade II
5. Mr S/62 yo CHF NYHA III ec DCM dd IHD (EF 20.4% (T))
Hipertensi
Dislipidemia
Dispepsia
Azotemia (Cre 1.9, eGFR 39 ml/min/1.73 m²) -- (1.2) 24/12 perbaikan
Hiperkalemia (5.4) -- (3.0) 24/12 hipokalemia
Hiperurisemia
4. Mr. MH/59 yo CHF NYHA III ec CAD2VD (Complete revas)
Post PCI di RCA dengan 1 DES pada CAD2VD, slow flow di LAD (26/12/22)
Post PPCI 2 DES di proximal-distal LAD pada CAD2VD (5/10/2022)
Dislipidemia
Hiperurisemia
2. Mr. SH/42 yo UAP Killip I TIMI 4/7
HFrEF
Hypertension
CKD stg V on HD
Anemia NN (Hb 5.8) 21/12/22 -- (8.8) 26/12
MALE WARD

NO NAME DIAGNOSIS
1. Ms. MA/ 26 yo Post ASD Closure+ TV repair
2. Mrs. DS/45 yo MASD II 22 mm L to R shunt
Moderate TR, Mild MR, Mild PR
PH
3. Mrs. E/ 33 yo CHF NYHA III e.c IHD (EF 38%)
CKD stg V
Pneumonia
HT, T2DM, dislipidemia
4. Mrs. SW/384yo Efusi perikard massive impending tamponade
Post pericardial window (20/12/22)
Efusi pleura massif post WSD (17/12/22)
G2P1A0 gestational week 8
Klinis SLE
FEMALE WARD

NO NAME DIAGNOSIS
1. Mrs. P/ 72 yo Obs Hipotension on HFpEF e.c IHD dd HHD (EF 62%)
AF NVR
AR moderate, MR moderate
Insuff renal
2. Mrs. Mi/ 77 yo ON PPM e.c TAVB with junctional Escape
Recent STEMI Anterior 2 month onset Killip I TIMI 4/14
3. Mrs. PS/ 57 yo Recent STEMI Anteroseptal Killip II TIMI 3/14
AHF on ACS
Dislipidemia
DCM
4. Mr. SU/ 58 yo Acute STEMI anterior extensive KILLIP I TIMI 4/14
Post PPCI 1 DES LAD on CAD2VD
HT
Dislipidemia
CC WARD

Case Ilustration
Identity
• Name : Mrs. M
• Age : 30 y.o
• Address : Bonang, Demak
• Marital status : Married
• Occupation : Tailor
• Hospitalized : December 6th ,2022
7

Anamnesis December 6th ,2022
Chief complaint : SOB
8
March 2021
On second month of pregnancy (G2P1A0)
Started to feel easily tired, accompanied by
Shortness of breath over a
moderate – heavy Activities
(walking > 1km, lifting heavy objects)
Accompanied by occasional ankle edema
Relieve with rest
October 2021
Hospitalized due to Severe
Preeclampsia (36 weeks GA),
Pregnancy was terminated
by SC.
August 2021
Hospitalized in RSDK due to
HT in pregnancy with
generalized edema.
November 2021
Edema resolved after delivery
But complaint of recurring SOB
on moderate to heavy
activities persisted

Anamnesis December 6th ,2022
Chief complaint : SOB
9
December 6th 2022
Complaint of SOB got worsen
Precipitated by mild activities (walking
around house, or doing simple chore)
Accompanied with cough and edema
almost in all body area
DOE(+), PND(+), OP(+)
Couldn’t be relieve with rest or medication
July 2022
Patient already felt better.
Edema resolved with current
medication.
Patient Didn’t control afterward
October 2022
SOB and occasional ankle swelling was
started to occur again with moderate to
heavy activities.
She took her last medication on early
September and didn’t took any
medication after.

History of past
illness
10
o No history of uncontrolled movement
o No history of reddish in body area
o No history of migratory joint pain
o No history of weakness half of body or speech
disturbance
Family History
o No family have the same illness with patient
o No history Family with congenital heart disease
Social History
o Was a tailor, stop working after having a
second child
o Had never Consume Alcohol Beverage

Recent Medication
• spironolakton tab 100 mg/24 h
• bisoprolol tab 5 mg / 24 h
• furosemid tab 40 mg/ 12 h
• kandesartan tab 16 mg/ 24 h
11

Riwayat Penyakit Dahulu
CAD
Risk
Factors
HTN (+)
DM (-)
Dyslipidemia
(-)
Fam.
History
(-)
CAD Risk Factors
Smoker
(-)
12

PHYSICAL EXAMINATION IN
‘ELANG PUTRI’ WARD
13

PHYSICAL
EXAMINATION
14
GENERAL CONDITION
Compos Mentis
Weight : 45 kg
Height : 155 cm
BMI : 18.7 kg/m2
ED (06/12/22) PUTRI WARD (23/12/22)
BP : 152/106 mmHg
Heart Rate : 95 bpm
RR : 24x/minute
SPO2 : 96 % room air
Temperature : 36.50C
BP : 126/85 mmHg
Pulse : 77 bpm
RR : 20x/minute
SPO2 : 98 % room air
Temperature : 36.50C

• Anemic (-/-), icteric (-/-)
Head
• JVP 5 +2 cm H2O
• Distended Neck vein (-)
• Facial Edema (+)
Neck
15

Heart
Inspection
• Ictus cordis cannot be seen
Palpation
• Ictus cordis palpated in ICS 5 anterior midaxillar line
• Heave (+)
• Thrill (-)
AUSCULTATION
• S1 S2 single regular murmur (-)
16

LUNG
• Inspection :
• Symetric while in static &
dynamic state
• Palpation :
• Vocal fremitus normal on
both side of the lung
• Percussion:
• Sonor on both side of the
lung
• Auscultation:
• Vesicular on all field
• Rales (+/+) 1/3 basal
• Wheezing (-/-)
• Pericardial friction rub (-/-)
ABDOMEN
• Inspection : Ascites (+)
• Auscultation : Normal Bowel
Sound
• Percussion : Shifting dullness (+)
• Palpation :
 Liver cannot be palpated
 Hepatojugular reflux (-)
 Ekstremitas
 Edema on upper and lower
extrimites (+/+/+/+)
17
EXTRIMITIES

EKG December 6th 2022
Interpretation
•Rhythm : Sinus
•Rate : 76 bpm
•Axis : normoaxis
•P wave(s): P mitrale lead II
•PR Interval: 140 ms
•QRS : Poor R
wave progression
•ST segmen: No Changes
•T wave(s): T inverted V4-
V6; II AVF; I AVL
•Conclusion
Sinur Ryhthm 76 bpm,
normoaxis, LAE, PRWP

THORAX X-RAY 6/12/22
Posteroanterior Description:
o Cardio Thoracic Ratio : 75%
o Apex shifting to laterocaudal
aspect
o Cephalization (+)
o Flat cardiac left waist border
o Double Contour
o Right heart border >1/3 right
heart diameter
o Sharp Costophrenic (+/-)
Lateral Description:
o Retrosternal and retrocardiac
space narrowing
Conclusion:
Cardiomegaly (LV, LA, RV,
RA), pulmonary edema, left
pleural effusion
19

25
Dec 8 th ,2022
Dec 13 th ,2022
Dec 14 th ,2022

31/8/21
LVH konsentrik
fungsi sistolik LV normal (LVEF 60%)
disfungsi diastolik grade II dengan
peningkatan LAP
mild MR, mild TR, mild PR
15/11/21
Efusi Pericardial loculated (+) mild 4-6mm
Efusi Pleura (+) sinistra
LVH konsentrik, RWMA(+)
Fungsi sistolik LV turun LVEF 37.1% (Biplane)
Disfungsi diastolik LV grade II
Fungsi sistolik RV normal
MR mild, TR mild
Echocardiografi
9/11/21
Efusi perikardial loculated (+) mild to
moderate10-15mm
Efusi pleura (+) sinistra
Dimensi ruang jantung dalam batas normal,
LVH konsentrik
Fungsi sistolik LV turun dengan LVEF 37.0%
(Biplane)
Fungsi sistolik RV normal
MR trivial, TR mild
Low probability for PH

29
19/12/21
Dilatasi LV, LVH konsentrik
Global hipokinetik
Fungsi sistolik LV turun dengan
LVEF : 32% (B)
Fungsi sistolik RV nomal
Disfungsi diastolik LV grade II
MR Mild, AR Mild, TR Mild
Low probability for PH
12/6/22
Dilatasi LA, LV
LVH konsentrik
LV sec (+)
Global hipokinetik
Fungsi sistolik LV turun dengan LVEF 25% (B)
Fungsi RV normal dengan TAPSE 21 mm
Disfungsi diastolik LV Grade III
AR mild, TR mild
Intermediate probability for PH

WORKING DIAGNOSIS
30
 Functional Diagnosis : Chronic Heart Failure functional class NYHA III
 Anatomical Diagnosis : Cardiomegaly (LV, LA, RV, RA)
 Etiological Diagnosis : Peripartum Cardiomyopathy dd HHD
• Additional Diagnoses :
– Susp Nephrotic Syndrome
– Azotemia

Management at Ward
31
IVFD NaCl 0.9% 10 tpm
Inj. Furosemide 20 mg/ 12 h
metokloperamide 10 mg / 8h
PO:
warfarin 2 mg/24 h
kandesartan tab 16 mg/ 24 h
Atorvastatin 20 mg/24 h
spironolakton 100 mg/24 h
bisoprolol 2,5 mg/24 h
diazepam 5 mg / 24 h
paracetamol 500 mg/ 8 h
NAC 200 mg/ 8 h
HCT 12,5 mg/ 12 h
KSR 1 tab/12 h
Lansoprazole 30 mg/24 h

Ao 21 mm
LA 38 mm
LVIDd 59 mm
EF 27% Teichz

Description
• LV Dilation
• Concentric LVH, intact IAS & IVS, thrombus (-), LV SEC (+), pericardial effusion (-)
• Global hypokinetic
• Reduced LV systolic function with LVEF : 27% (Teichz), 32% (Biplane), GLS : -7.7%
• Reduced LV diastolic function with E/A : 1.73, E/e’ : 15.13, EDT : 115 ms
• Normal RV systolic function with TAPSE : 23 mm
• AoV : 3 cusps, Mild AR (+), AS (-)
• MV : MS (-) , Mild MR (+)
• PV : Mild PR (+), PS (-)
• TV : Mild TR (+), TS (-)
• PH : Low probability for PH

Conclusion
 LV dilation
 LVH concentric
 Global hypokinetic
 Reduced LV systolic function with LVEF : 32% (B)
 LV Diastolic dysfunction grade II
 Normal RV systolic function
 AR Mild, TR Mild, MR Mild, PR Mild

Echocardiography
Mrs. M (AUGUST)

Ao 28 mm
LA 38 mm
LVIDd 49 mm
EF 60.1% Teichz

Description
• Concentric LVH, intact IAS & IVS, thrombus (-), pericardial effusion (-)
• Global normokinetic
• Normal LV systolic function with LVEF : 60% (Teichz)
• Reduced LV diastolic function with E/A : 1.15, E/e’ : 15.8, EDT : 162 ms
• Normal RV systolic function with TAPSE : 25 mm
• AoV : 3 cusps, AR (-), AS (-)
• MV : MS (-) , Mild MR (+)
• PV : Mild PR (+), PS (-)
• TV : Mild TR (+), TS (-)
• PH : Low probability for PH

Conclusion
 LVH concentric
 Global normokinetic
 Normal LV systolic function with LVEF : 60% (T)
 LV Diastolic dysfunction grade II
 Normal RV systolic function
 TR Mild, MR Mild, PR Mild

Bersifat kronis Waxing and Waning
Flare dapat muncul saat remisi
Morbiditas dini karena penyakit. | morbiditas lanjut karena lama penyakit dan terapi
70
Perjalanan Penyakit
Bertsias, et al. Systemic Lupus Erythematosus: Pathogenesis and Clinical Features. EULAR Textbook on Rheumatic Diseases: ch 20, pg 476- 505.
Levy, et al. Systemic Lupus Erythematosus in Children and Adolescents. Pediatr Clin North Am. Author manuscript; available in PMC 2013 April 01.

71
Patogenesis
Bertsias, et al. Systemic Lupus Erythematosus: Pathogenesis and Clinical Features. EULAR Textbook on Rheumatic Diseases: ch 20, pg 476- 505.

72
Diagnosis
Charras, et al. Systemic Lupus Erythematosus in Children and Young People. Current Rheumatology Reports (2021) 23: 20.

73
Diagnosis

74
Diagnosis

75
Diagnosis

76
Diagnosis

94
Preeclampsia is defined as the presence of
(1) a systolic blood pressure (SBP) greater than or equal to 140 mm Hg or a
diastolic blood pressure (DBP) greater than or equal to 90 mm Hg or higher,
on two occasions at least 4 hours apart in a previously normotensive
patient, OR
(2) an SBP greater than or equal to 160 mm Hg or a DBP greater than or equal to
110 mm Hg or higher. (In this case, hypertension can be confirmed within
minutes to facilitate timely antihypertensive therapy.)
proteinuria of greater than or equal to 0.3 grams in a 24-hour urine specimen, a
protein (mg/dL)/creatinine (mg/dL) ratio of 0.3 or higher, or a urine dipstick
protein of 1+ (if a quantitative measurement is unavailable) is required to
diagnose preeclampsia.

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