Case Report Paper HT Emergency NSTE-ACS in AVB

Challenging Case Report
Bradyarrhytmia presenting chest pain in
patient with Emergency Hypertension.

Muhammad Nur Ardhi Lahabu, MD
Dabo General Hospital
Riau Island, Indonesia

Muhammad Nur Ardhi Lahabu, MD
Education
2017-2021 Medical degree at Batam University
Medical Profession programm at Batam University
2021-2023
2023 Medical Doctor
Working Experiences @utylahabu

2024 - Now Internship Doctor at Dabo General Hospital, Lingga Island,
Riau Islands, Indonesia
Achievements
2023 Highest Score UKMPPD CBT in Batam University 2023rd August

Period (85.5)
Highest Score UKMPPD OSCE in Batam University 2023rd August
Period (90.59)
Introduction
Significant hypertension and bradycardia are often seen

together in clinical practice. Severe hypertension sometimes
using multidrugs therapy can lead to bradycardia. In this case
we report an emergency hypertension with 1st degree AV
Block in a patient that drop out of treatment.
Case Illustration
Mrs. P
61 Years old
Came to the Emergency Door with: Chest Pain
Chief Complaints: Chest Pain for the last four hours before arrival. chest pain described as crushing weight chest pain and also
radiated to left shoulder, neck and jaw also. Chest pain emerged during rest, no nausea either vomiting. Patient complaining
swollen leg and face for the last two days, patent also complaining shortness of breath, Shorthness of breath arise when the
patient at rest and worsening by activity. patient use single two pillows during asleep and often awake at night because of
breathless. No headache no blurred vision and no sudden weakness of the limbs found, occasionally cough with clear sputum
no hemaptoe and no loss weight.
Precipating Factor: Not compliant for treatment.
Medical History:
Treated by Internist for hypertension and T2DM for almost two years, and having a severe bradycardia with disorientation.
Previously treated with:

The patient didn’t remember the medication, but it is confirmed that patient have using insulin.
Clinical Examination
Mrs. P
61 Years old
Came to the Emergency Door with: Chest Pain
Vital Sign Thorax & Abdomen Extremity

• GCS: E4V5M6 (Compos Mentis)
• Thorax: - Deformity (-)
• Blood Pressure: 243/86 mmHg
- Lungs: Rales (-/-), Ronkhi (+/+), - Warm Extremities
• Heart Rate: 47 bpm reguler
Vesicular (+/+), - Pretibial Pitting
• Resp rate: 16 breath/min
- Heart: Murmur: (-), Gallop (-), palpitation (-) Edema (+)
• 02 Saturation: 98 % on room air
- CRT: < 2 s
Head • Abdomen:
• Anemic Conjunctiva (-/-) - Metallic sound (-), Distended (+),
• Icteric Sclera (-/-) Darm steifung (-), Darm Contour(-)
• Face Drooping (-) Tenderness (-),
• JVP increased (-)
ECG INTERPRETATION:
RHYTM: 1st Degree AV Block ST Segment: ST Depression in v4-v6 leads Conclussion:
RATE: Regular, 47 bpm T Wave: Deep Inverted T wave in v3-v6, I, aVL 1st degree AV Block, regular 47bpm
AXIS: Normoaxis BBB: no bundle branch block Normoaxis with Anterolateral
ischemic.
PR INTERVALS: 0,28 s constant Hypertrophy: no Hypertrophy
Radiology Findings
INTERPRETATION:
Thorax AP Supine
Trachea Midline
Bone intact
no swollen Soft Tissue
Cor:
- Elongatio Aorta (+)
- CTR > 60%
Pulmo:
- No thickened Broncovascular
- No swolle of Hilus
- Costofrenic angle fine
Conclude: Cardiomegaly with Aortic

Elongation
Laboratory Finding
(15/04/2024)
EXAMINATION RESULT UNIT NORMAL VALUE
HEMATOLOGI
WBC 19,19 10³/uL 5,00-10,00
RBC 4,30 106/uL 4,00-5,50

HGB 11,9 g/dL 12,0-17,4
MCV 92,2 fL 76,0-96,0
MCH 37,0 pg 27,0-32,0
MCHC 40,2 g/dL 31,0-38,0
PLT 242 106/uL 150-400
Blood Glucose 306 mg/dl <200 mg/dl
Laboratory Finding
(15/04/2024)
EXAMINATION RESULT UNIT NORMAL VALUE
ELEKTROLIT
Kalium (K+) 3,7 Mmol/L 135-145 mmol/L
Natrium (Na) 135 Mmol/L 3.6-5,2 mmol/L

Klorida (Cl) 103 Mmol/L 98-107 mmol/L
Conclussion: NORMAL
FUNGSI GINJAL
Ureum 61 mg/dl 12,8-42,8 mg/dl
Creatinin 0,8 mg/dl 0,7-1,2 mg/dl

Conclussion: Mild loss of Kidney Function (eGFR: 84mL/min/1.73m2)
Diagnosis
Symptomatic 1st degree AV Block

Emergency Hypertension
Anterolateral NSTE-ACS
Acute de novo heart failure
Treatment Plan
1. IVFD NaCl 0,9% 20 tpm

2. Aspirin tab 4x80 mg
3. Clopidogrel 4x75 mg
4. Atorvastatin 1x40 mg
Hospitalization
5. Sulfas Atropin IV 1x1 mg
6. Nicardipin drip 5ml/hour titrate
in HCU
1ml/15 mnt
7. Candesartan tab 1x16 mg
8. Amlodipine tab 1x10 mg
Discussions
This case interested us due to the combination of bradycardia and a hypertensive emergency who drop out of
treatment for 2 year.

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Challenging Case Report

Bradyarrhytmia presenting chest pain in

patient with Emergency Hypertension.

Dabo General Hospital

Riau Island, Indonesia

Working Experiences @utylahabu

2023 Highest Score UKMPPD CBT in Batam University 2023rd August

Significant hypertension and bradycardia are often seen

Precipating Factor: Not compliant for treatment.

Previously treated with:

Vital Sign Thorax & Abdomen Extremity

Conclude: Cardiomegaly with Aortic

RBC 4,30 106/uL 4,00-5,50

Natrium (Na) 135 Mmol/L 3.6-5,2 mmol/L

Creatinin 0,8 mg/dl 0,7-1,2 mg/dl

Symptomatic 1st degree AV Block

1. IVFD NaCl 0,9% 20 tpm

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