Oleh: dr. Faskanita M. NadapdapPembimbing: dr. Leonard Parlindungan, Sp.PD

INTERNSHIP RSUD. SANGGAU

EPIDEMIOLOGI5.1 juta penduduk Amerika terkena gagal jantungDiperkirakan akan meningkat 25% di tahun 2030Ras kulit hitam (Afrika) mempunyai resiko tinggi terkena gagal jantung.20% menyerang usia 40 tahun.

(The current 2013 ACCF/AHA Guideline Management of Heart Failure)

EPIDEMIOLOGI> 650.000 kasus baru per tahun dalam dekade terakhir.Tingkat kematian 50% dalam 5 tahun setelah pasien didiagnosis menderita gagal jantung.Di Amerika, pengeluaran negara 40 juta $US per tahun nya utk fasilitas kesehatan dan obat-obatan gagal jantung.

(The current 2013 ACCF/AHA Guideline Management of Heart Failure)

EPIDEMIOLOGIPoliklinik Penyakit Dalam RSCM tahun 2006 didapatkan 2,30% kasus gagal jantung (GJ) dari 6511 kunjungan,Di Ruang Rawat Inap, didapatkan 4,15% dari 5200 pasien.Menurunkan kualitas hidup dan jadi indikasi rawat inap terbanyak pada usia 65 tahun

DEFINISISuatu sindroma klinis yang kompleks yang bisa diakibatkan oleh setiap kelainan fungsi maupun struktur jantung yang berakibat pada gangguan pengisian dan /atau pemompaan ventrikel.

(The current 2013 ACCF/AHA Guideline Management of Heart Failure)

DEFINISIGagal Jantung vs Gagal Jantung Kongestif

Terminologi gagal jantung kongestif tidak digunakan lagi saat ini karena tidak semua pasien mengalami overload cairan saat awal evaluasi.

(The current 2013 ACCF/AHA Guideline Management of Heart Failure)

FAKTOR RISIKOHipertensi, Diabetes Mellitus, Sindrom Metabolikabdominal adiposity,hypertriglyceridemia, low high-density lipoprotein, hypertension, and fasting hyperglycemiaAtherosclerotic Disease

ETIOLOGIInfark Miokard (40%)Kardiomiopati : bahan kimia & obat-obatan (20%)Valvular (15%)Penyakit Jantung Hipertensi (10%)Infeksi : Myocarditis (8%) Kongenital : ASD, VSD, PDA, Coarc-Ao (7%)

Myocardial infarctionCoronary thrombosisMyocardial ischaemiaCoronary artery diseaseAtherosclerosis, Left ventricular hypertrophyRisk factors(Hypertension, LDL, Diabetes, etc)Arrhythmia & Loss of muscleSuddendeathRemodellingVentricular dilatationHeart failureEndstageHeart DiseaseDzau & Braunwald, 1991

TIPE-TIPEGagal jantung dengan penurunan ejection fraction ventrikel kiri (HFrEF) = gagal jantung sistolik LVEF < 40%.= menurunnya fungsi pompa jantung

Gagal jantung dengan dengan preserved LVEF (HFpEF) = gagal jantung diastolik LVEF > 50% = 0tot jantung menebal dan kaku= pengisian volume darah di jantung tidak sempurna

MENURUT FASEGagal jantung kronik karakteristik berupa remodeling progresif ruang ventrikel kiri, yang kemudian akan diikuti juga dengan dilatasi pada ketiga ruang lain secara progresif. Ventrikel kiri bertambah besar, berbentuk lebih sferik setelah beberapa bulan sampai tahun, sehingga menurunkan fraksi ejeksi ventrikel kiri .

MENURUT FASE2. Gagal jantung akut dapat ditinjau dari berbagai sudut pandangan yang menjadipenyebab utamanya :a) Edema paru akutb) Syok kardiogenikc) Eksaserbasi akut pada gagal jantung kronik

DIAGNOSISSYMPTOMSOverload cairanDyspneaOrthopneaParoxysmal nocturnal dyspneaCardiac asthmaCheyne-Stokes RespirationFatigue, weaknessExercise intoleranceUrine Output menurunConfusionLetargiNokturiaAnoreksiaPHYSICAL SIGNSRalesTakikardiDisplaced PMI (point of maximal impulse = apex)S3 (ventricular gallop)S4 (atrial gallop)Pulmonary HTN (loud P2)Distensi vena leherPembesaran heparEdema periferAscitesEfusi pleuraCardiac CachexiaJaundiceKulit pucat dan dinginPulsus alternans

Compensatory Mechanisms:Renin-Angiotensin-Aldosterone SystemRenin + AngiotensinogenAngiotensin I Angiotensin II Peripheral Vasoconstriction Afterload Cardiac OutputHeart Failure Cardiac Workload Preload Plasma Volume Salt & Water Retention Edema Aldosterone SecretionACE KaliuresisBetaStimulation CO Na+Fibrosis

Kriteria FraminghamKriteria MayorPNDDistensi vena leherKardiomegaliHepatojugular reflux (+)S3 gallopRalesEdema paru akutTVJ > 16cmH2O

Kriteria MinorSesak saat aktivitasBatuk malam hariTakikardia ( 120 x/i)Efusi pleuraHepatomegaliEdema ekstremitasKapasitas vital paru 1/3 dari normal(Setidaknya 1 kriteria mayor dan 2 kriteria minor)

EkokardiografiGold standard diagnosis. Melihat besar ruang-ruang jantung, kontraktilitas sistolik dan diastolik, serta menilai katup dan dinding jantung dapat dinilai. Nilai fraksi ejeksi ventrikel kiri normal adalah > 50%.

EkokardiografiDapat juga ditentukan apakah terdapat gagal jantung diastolik dengan menilai aliran/arus darah pada pemeriksaan Doppler pada katup mitral dan pulmonal. Dapat melihat fungsi ventrikel kanan sehingga dapat ditentukan apakah ada kemungkinan gagal jantung kanan.

Pemeriksaan LaboratoriumDarah Lengkap anemia dapat memicu gagal jantungElektolit dan creatinin sebelum memulai terapi diuretik dosis tinggiKGD Puasa melihat kemungkinan DMHormon TiroidThyrotoxicosis pada atrial fibrilasiHipotiroid pada gagal jantung.Profil Besi skrining hereditary hemochromatosisANA, untuk melihat kemungkinan LupusViral, pada suspek myokarditis

BNP dan NT-proBNPBNP (Brain Natriuretic Peptide) dan juga NT-pro BNP (N terminal protein BNP) yang lebih sensitif dari BNP. BNP diproduksi bila terjadi regangan pada dinding ventrikel kiri, sehingga pada keadaan gagal jantung kadar BNP ataupun NT pro BNP akan meningkat. BNP diproduksi juga oleh jaringan otak dan ginjal sehingga pada keadaan gagal ginjal kadarnya juga akan meningkat, karena ekskresinya melalui ginjal.

BNP dan NT-proBNPPenglepasan BNP meningkat seiring dengan menurunnya fungsi ventrikel kiri. Peningkatan BNP merupakan tanda patognomonis. Nilai cutoff NT pro BNP (PRIDE) tergantung pada usia : < 50 tahun adalah > 450 pg/ml > 50 tahun adalah > 900pg/ml nilai < 300 pg/ml, dugaan chf dapat dihilangkan.Test NT pro BNP punya nilai sensitif spesifik tinggi untuk mendiagnosis gagal jantung akut dengan sesak nafas.

Kardiomegali

Kongesti Pembuluh darah Paru

Edema Pulmonal akibat Gagal Jantung

Kerley B lines

EKGMelihat secara spesifik etiologi:Penyakit jantung iskemik Dilated cardiomyopathy: first degree AV block, LBBB, Left anterior fascicular blockAmyloidosis: pseudo-infarction patternIdiopathic dilated cardiomyopathy: LVHExercise TestingSebaiknya dilakukan pada awal evaluasi

Arteriografi KoronerPada pasien gagal jantung yang punya riwayat angina atau iskemiaPada pasien nyeri dada cardiac atau noncardiac, pasien dengan duggan kelainan anatomi jantung, dan pada pasien dengan /suspek penyakit koroner tanpa angina.Menilai cardiac output, derajat kerusakan ventrikel kiri, dan tekanan end-diastolic ventrikel kiri.

Biopsi EndomiokardiumTidak lazim dilakukanHanya dilakukan pada kardiomiopati akibat infeksi virus

Koreksi faktor sistemikDisfungsi tiroidInfeksiDM tidak terkontrolHipertensiModifikasi gaya hidupKurangi konsumsi garam dalam makanan ( 2 g/hari)Hentikan konsumsi alkohol dan merokokKepatuhan minum obatKurangi BB pada obesitasKurangi asupan cairan ( 1.5 L/day) terutama bila hiponatremiaMaksimalkan pengobatanHentikan obat-obatan yang dapat memperparah gagal jantung (NSAIDS, antiarrhythmics, calcium channel blockers)PENATALAKSANAAN

MEDIKAMENTOSAJessup M and Brozena S. N Engl J Med 2003;348:2007-2018

DiuretikLoop diuretikFurosemide, buteminideUntuk mengontrol cairan dan mengurangi gejalaDiuretik Hemat KaliumSpironolactone, eplerenoneMembantu meningkatkan diuresisMenjaga keseimbangan kaliumMeningkatkan survival rate CHF

ACE InhibitorMeningkatkan survival rate pada pasien gagal jantung beratMulai dengan dosis kecil lalu ditingkatkan:Enalapril 2.5 mg po BIDCaptopril 6.25 mg po TIDLisinopril 5 mg po QDailyBila intoleransi, beri ARB

Beta BlockerBeta blocker (carvedilol, metoprolol, bisoprolol) dapat meningkatkan survival rate pasien NYHA class II to III , dan kadang pada pasien yang class IV.Kontraindikasi:HR 0,24 s, AV block Derajat 2 dan 3

Hydralazine plus NitratesDosis:HydralazineMulai dari 25 mg po TID, kemudian dinaikkan perlahan hingga 100 mg po TIDIsosorbide dinitrateMulai dari 40 mg po TID/QIDMenurunkan mortalitas, insidens rawat inap dan memperbaiki kualitas hidup pasien.

DigoxinGiven to patients with HF to control symptoms such as fatigue, dyspnea, exercise intoleranceShown to significantly reduce hospitalization for heart failure, but no benefit in terms of overall mortality.

Other important medication in Heart Failure -- StatinsStatin therapy is recommended in CHF for the secondary prevention of cardiovascular disease.Some studies have shown a possible benefit specifically in HF with statin therapyImproved LVEFReversal of ventricular remodelingReduction in inflammatory markers (CRP, IL-6, TNF-alphaII)

Meds to AVOID in heart failureNSAIDSCan cause worsening of preexisting HFThiazolidinedionesInclude rosiglitazone (Avandia), and pioglitazone (Actos)Cause fluid retention that can exacerbate HFMetforminPeople with HF who take it are at increased risk of potentially lethic lactic acidosis

Implantable Cardioverter-Defibrillators for HFSustained ventricular tachycardia is associated with sudden cardiac death in HF.About one-third of mortality in HF is due to sudden cardiac death.Patients with ischemic or nonischemic cardiomyopathy, NYHA class II to III HF, and LVEF 35% have a significant survival benefit from an implantable cardioverter-defibrillator (ICD) for the primary prevention of SCD.

Management of Refractory Heart FailureInotropic drugs:Dobutamine, dopamine, milrinone, nitroprusside, nitroglycerinMechanical circulatory support:Intraaortic balloon pumpLeft ventricular assist device (LVAD)Cardiac TransplantationA history of multiple hospitalizations for HFEscalation in the intensity of medical therapyA reproducable peak oxygen consumption with maximal exercise (VO2max) of < 14 mL/kg per min. (normal is 20 mL/kg per min. or more) is relative indication, while a VO2max < 10 mL/kg per min is a stronger indication.

Overview of Device Therapy*Biventricular PacingVentricular DysynchronyAbnormal ventricular conduction resulting in a mechanical delay and dysynchronous contraction

Overview of Device Therapy

Cardiac Resynchronization TherapyKey PointsIndicationsModerate to severe CHF who have failed optimal medical therapyEF

Device Shown:Combination Pacemaker & DefibrillatorDefibrillators (ICDs)

Artificial Hearts

DAFTAR PUSTAKA

Heart Failure Treatments: Medication TypesACE inhibitor (angiotensin-converting enzyme) ARB (angiotensin receptor blockers)Beta-blockerDigoxinDiuretic

Aldosterone blockadeType What it doesExpands blood vessels which lowers blood pressure, neurohormonal blockadeSimilar to ACE inhibitorlowers blood pressureReduces the action of stress hormones and slows the heart rateSlows the heart rate and improves the hearts pumping function (EF)Filters sodium and excess fluid from the blood to reduce the hearts workloadBlocks neurohormal activation and controls volume

Lifestyle Changes

Eat a low-sodium, low-fat dietLose weightStay physically activeReduce or eliminate alcohol and caffeineQuit SmokingWhat WhySodium is bad for high blood pressure, causes fluid retentionExtra weight can put a strain on the heartExercise can help reduce stress and blood pressureAlcohol and caffeine can weaken an already damaged heartSmoking can damage blood vessels and make the heart beat faster

Rational for Medications(Why does my doctor have me on so many pills??)Improve SymptomsDiuretics (water pills)digoxinImprove SurvivalBetablockersACE-inhibitorsAldosterone blockersAngiotensin receptor blockers (ARBs)

**Many patients with advanced systolic heart failure exhibit significant inter- or intraventricular conduction delays that disturb the synchronous beating of the left and right ventricles so that they pump less efficiently. This delayed ventricular activation and contraction is referred to as ventricular dysynchrony and is easily recognized by a wide QRS complex on an ECG.This IVCD (inter- or intraventricular conduction delay) typically has left bundle branch morphology.

**Click on animation. Dr. (Name) says:Some people with Class III and IV heart failure can benefit from a heart failure pacemaker that can help your heart beat more efficiently by coordinating or synchronizing the way the heart beats, so your heart pumps more efficiently. It works by automatically checking your heart function 24 hours a day.This type of heart device is also called cardiac resynchronization therapy or CRT. You may also hear the term biventricular pacing. All refer to the same kind of treatment.Treatment with a heart device may make you feel better.Although many people experience dramatic improvements in their quality of life and in their heart failure symptoms, results may vary. Not everyone responds to the treatment in the same way.It is also important to note that heart failure pacemakers do not cure heart failure--a heart failure pacemaker is part of an overall treatment plan. Describe heart failure pacemaker device:A heart failure pacemaker is about the size of a small pocket watch that contains a battery and computer circuitry to correct your heart rhythm and help your heart beat more efficiently. Small insulated wires called leads connect the device to the heart.Were going to pass around a plastic replica of a Medtronic combination heart failure pacemaker and defibrillator pacemaker . Facilitators circulate and pass around replicas and collect them.Before I move on, Id like to say a few words about Medtronic, the company helping us put on the seminar today.Medtronic was the first company to introduce a pacemaker in the United States. Physicians worldwide have prescribed heart failure pacemakers for more than 120,000 patients. Other people with heart failure are in danger of having heartbeats that are irregular and/or too fast.These irregular heart beats can cause you to feel short of breath and light headed. Such episodes may also be life threatening if not treated quickly.Some heart devices also contain a defibrillator in addition to the special kind of pacemaker. This combination device also sends out small electrical signals to restore your normal heart rhythm. If the small signals do not work, the device sends out a shock to reset your heart rhythm. This kind of device is also used to treat SCA.

*Lifestyle changes involved in managing heart failure:Discuss diet and exercise in some detail:Staying active does not mean training as if you were going to run a marathon: but can simply mean regular walks. You can start slowly and build up under the direction of your doctor.Can reduce sodium in your diet by focusing on eating fresh meats, fruits, and vegetables; reading labels: asking questions when you eat out; and getting a low-sodium cookbook. Lifestyle changes are things you can do to influence how your feel.It may seem difficult to accomplish these things, but they are an essential part of treating heart failure.There are many resources to help you get started in incorporating these changes into your life. List any.Also, ask your friends and family for support.