Patient was apparently all-right one and half years back, when he developed sudden onset severe constricting type retrosternal pain at rest with radiation to left arm associated with shortness of breath, nausea and vomiting. He was admitted in the local hospital , ECG was done and told to have heart attack. He was discharged after 7 days and advised to attend a higher cardiac centre for coronary angiography. But he didn’t followed up after that and was on irregular oral medication. A 62 years old diabetic, smoker, non-hypertensive male presented with acute coronary syndrome like symptoms one and half year back followed by angina of CCS class II which progressed to CCS class III over last 3 months. Patient also had shortness of breath which progressed from NYHA Class II to NYHA Class IV over last 3 months with history suggestive of orthopnea. D/D Ischemic heart disease Hypertrophic cardiomyopathy Valvular heart disease (Aortic valvular disease) Dilated cardiomyopathy RSOV

1. CARDIOLOGY CASE
PRESENTATION- ISCHEMIC
CARDIOMYOPATHY
DR DEBASISH MOHAPATRA
DM CARDIOLOGY

2. • Patient xyz, 62 years diabetic, non-hypertensive male, farmer by occupation
presented to our hospital with the chief complain of:
1. Chest pain – one and half year
2. Shortness of breath – 3 months.
• Informant patient himself, reliable.
• Date of examination 1th Sept. 2023.

3. HISTORY OF PRESENT ILLNESS:
• Patient was apparently all-right one and half years back, when he developed
sudden onset severe constricting type retrosternal pain at rest with radiation to left
arm associated with shortness of breath, nausea and vomiting. He was admitted
in the local hospital , ECG was done and told to have heart attack. He was
discharged after 7 days and advised to attend a higher cardiac centre for
coronary angiography. But he didn’t followed up after that and was on irregular
oral medication.
• After that patient was experiencing chest pain, while on climbing stairs rapidly
and walking more than two blocks on level ground. The pain was constricting in
nature, retrosternal in location usually begins gradually and reaches its maximum
intensity over a period of few minutes and relieved within few minutes of taking
rest with radiation to left arm and associated with sweating.

4. • But for the last 3 months this chest pain progressed to such an extent that he was
having chest pain on walking one block on level ground and climbing one flight of
stairs in normal conditions and at normal pace.
• He was also complaining of shortness of breath for last 3 months which was
insidious onset, gradually progressive, which initially occurred on climbing two
flight of stairs at normal pace then progressed to such an extent that he was
dyspneic while going to bathroom and during dressing & undressing.
• But for last 7 days before hospitalisation, he was having shortness of breath at
rest, which aggravated immediately after lying supine.
• Shortness of breath was not associated with wheezing or any seasonal variation.

5. • Patient doesn’t complain of palpitation or syncope.
• There is no history of fever, cough with expectoration.
• There is no history of limb weakness, altered sensorium, slurring speech.
• There is no history suggestive of intermittent claudication or pain in extremities.
• There is no history of decreased urination or abdominal swelling.

6. PAST HISTORY
• Patient is a known case of Type II Diabetes mellitus for last 10 years on regular
medication.
• No history of hypertension or thyroid disorders or CVA.
• No other significant medical or surgical history.

7. FAMILY HISTORY
• There is no relevant positive family history.

8. PERSONAL HISTORY
• He is taking normal mixed diet.
• Bladder and bowel function normal.
• He is habituated to cigarette smoking, 10-15/day since 30 years.
• He is married and having 2 children.

9. TREATMENT HISTORY
• He was receiving medications from local hospital for chest pain and shortness of
breath.
• After taking these medications, his urination has increased in frequency and
symptoms subsided to some extent.
• No h/o hospitalisation after index event.

10. SUMMARY
• A 62 years old diabetic, smoker, non-hypertensive male presented with acute
coronary syndrome like symptoms one and half year back followed by angina of
CCS class II which progressed to CCS class III over last 3 months. Patient also
had shortness of breath which progressed from NYHA Class II to NYHA Class IV
over last 3 months with history suggestive of orthopnea.

11. DIFFERENTIAL DIAGNOSIS
• Ischemic heart disease
• Hypertrophic cardiomyopathy
• Valvular heart disease (Aortic valvular disease)
• Dilated cardiomyopathy
• RSOV

12. GENERAL EXAMINATION
• Patient is conscious oriented to time place and person.
• Propped up decubitus.
• Height = 160cms, Wt- 68 kg, BMI- 26.5 kg/m2
• There is no pallor, icterus, cyanosis, clubbing, lymphadenopathy.
• B/L pitting pedal edema present
• Pulse rate - 110/min, regular, low volume and normal in character, no radio-radial or radio-femoral delay, arterial wall
is palpable. All peripheral pulses are felt.
• Blood Pressure – 100/80mmHg in right upper arm. 96/78 mmHg in left upper arm
108/80 mmHg in both lower limb

13. • Respiratory Rate - 22/min regular, abdomino-thoracic.
• Temperature – afebrile
• JVP- Raised 8 cm above the sternal angle, pulsatile with prominent a wave.

14. CARDIOVASCULAR EXAMINATION:
INSPECTION & PALPATION
• Chest bilaterally symmetrical.
• Precordium is normal.
• No scar mark.
• Apex beat is at left 6th intercostal space just lateral to mid clavicular line,
hypokinetic in character, with medial retraction- LV type.
• No palpable heart sound, no thrill.
• Grade II parasternal lift.

15. PERCUSSION
• Liver dullness starts from right 5th ICS along MCL.
• Right heart border is sub-sternal.
• Apex corresponds to left heart border.
• Left 2nd ICS is resonant.

16. ASCULTATION
• First heart sound is soft.
• Second heart sound: P2 is loud with narrow split.
• LV S3 heard. No other added sound.
• A pansystolic, soft blowing murmur plateau in configuration of grade III/VI heard
over the apex with left lateral decubitus position with breath held in expiration
without any radiation.

17. RESPIRATORY SYSTEM EXAMINATION:
• Chest B/L symmetrical
• B/L Vesicular breath sound with fine basal crepitations.
• Abdominal Examination:
• Abdomen is soft.
• Tender non-pulsatile hepatomegaly palpable 4 finger breadth below right costal
margin, with liver span of 17 cm.
• No other organomegaly.

18. PROVISIONAL DIAGNOSIS
• Acute decompensated heart failure in a patient of ischemic cardiomyopathy with
biventricular failure with moderate PAH in normal sinus rhythm currently in NYHA
class III.

19. CHEST X RAY

20. 12 LEAD ECG

21. THANK YOU