Penanganan Gagal Jantung Pada Pelayanan Primer ( Dr. Todung )

PENANGANAN GAGAL

JANTUNG PADA PELAYANAN

PRIMER

Dr.TODUNG D.A.SILALAHI SpPD,K-KV,FINASIM

CARDIOVASCULAR DIVISION

DEPARTEMENT OF INTERNAL MEDICINE UKRIDA

2013

Definisi Gagal Jantung

supply unequal with demand

Epidemiologi

Gagal jantung mempengaruhi >20

juta pasien di dunia

Meningkat seiring pertambahan usia,

dan mengenai pasien usia lebih dari

65 tahun sekitar 6-10%

laki-laki > wanita.

Classification

a. Location:

left-side heart failure, right side heart failure

or biventricular.

b. Function :

- Sistolic (contraction) : MI, Cardiomyopathy

- Diastolic function (relaxtation or filling) :

valve MS, LVH

c. Blood volume :

- low output: Myocardial Infarction, MR, AS

- high output: Anemia, Hyperthyroid

Chronic heart failure

In the United States (the National Health and Nutrition Examination Survey

(NHANES I) found the following causes ranked by Population Attributable

Risk score

Ischaemic heart disease 62% ,Cigarette smoking 16%

Hypertension (high blood pressure) 10%, Obesity 8%, Diabetes 3%

Valvular heart disease2% (much higher in older populations).

An Italian registry of over 6200 patients with heart failure showed the following

underlying causes:

Ischaemic heart disease 40%

Dilated cardiomyopathy 32%

Valvular heart disease 12%

Hypertension 11% Other 5%.

Acute decompensation

Chronic stable heart failure may easily decompensate

, This most commonly results from an intercurrent illness

(such as pneumonia), myocardial infarction (a heart

attack), arrhythmias, uncontrolled hypertension, or a

patient's failure to maintain a fluid restriction, diet, or

medication. Other well recognized precipitating

factors include anemia and hyperthyroidism which

place additional strain on the heart muscle.

Signs and symptoms

Dyspnea

Fatigue

Diaphoresis

Paroxysmal nocturnal dyspnea

Chest pain as the initial complaint

Swelling in the legs

Discomfort in the upper abdomen the right

Diagnosis

Gold standard ?

"Framingham criteria”, the "Boston criteria“, the

"Duke criteria“ and (in the setting of acute

myocardial infarction) the killip class

Framingham criteria

requires the simultaneous presence of

at least 2 of the following major

criteria

1 major criterion in conjunction with 2

of the following minor criteria

Major criteria:

Cardiomegaly on chest radiography

S3 gallop a third heart sound

Acute pulmonary edema

Paroxysmal nocturnal dyspnea

Crackles on lung auscultation

Central venous pressure of more than 16 cm

H2O at the right atrium

Jugular vein distension

Positive abdominojugular test

Weight loss of more than 4.5 kg in 5 days in response to

treatment (sometimes classified as a minor criterium

Minor criteria

Tachycardia of more than 120 beats per minute

Nocturnal cough

Dyspnea on ordinary exertion

Pleural effusion

Decrease in vital capacity by one third from

maximum recorded

Hepatomegaly

Bilateral ankle edema

NYHA (New York Heart Association)

Class % of

patients

Symptoms

I 35% No symptoms or limitations in ordinary physical

activity

II 35% Mild symptoms and slight limitation during

ordinary activity

III 25% Marked limitation in activity even during minimal

activity. Comfortable only at rest

IV 5% Severe limitation. Experiences symptoms even at

rest

Imaging

Chest X-rays : Kerley lines, cuffing of the areas

Echocardiography : EF 50-80%

Electrophysiology

Arrhythmias

Ischemic heart disease

Right and left ventricular hypertrophy

presence of conduction delay or abnormalities

(e.g. left bundle branch block)

Blood tests

electrolytes (sodium, potassium)

measures of renal function, liver function

tests, thyroid function tests, a complete blood count,

and often C-reactive protein if infection is

suspected.

An elevated B-type natriuretic peptide (BNP) is a

specific test indicative of heart failure, with

a sensitivity of 85% and specificity of 84% in

detecting heart failure

Angiography

Management

1 Diet and lifestyle measures

1.1 Fluid restriction

2 Pharmacological management

2.1 Angiotensin-modulating agents : ACE inhibitor

2.2 Diuretics : Furosemide, HCT, Spironolactone

2.3 Beta blockers : bisoprolol

2.4 Positive inotropes: digoxin

2.5 Alternative vasodilators :ISDN, Hydralazine

2.6 Aldosterone receptor antagonists :spironolactone

2.7 Recombinant neuroendocrine hormones :Nesiritide

2.8 Vasopressin receptor antagonists :Tolvaptan

3 Devices : EF <35% CRT

4 Surgery : CABG, Heart transplant