Journal Reading - gagal jantung kongestif

7/28/2019 Journal Reading - gagal jantung kongestif

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W O R O A S R I A T I N U R J A N N A H

HEART FAILURE IN THE

ELDERLY


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Definition

Heart failure a complex clinical syndrome resultingfrom the inability of the heart to adequately supply themetabolic demands of tissues, or do so only with elevatedfilling pressures


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Epidemiology

400,000 new cases in the United States every year Incidence increases progressively in both genders

according to age


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Clinical Diagnosis

Fatigue Dyspneu

Orthopnea

Lower extremity edema

Reduced exercise tolerance


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Clinical Diagnosis

Confusion Memory deficit

Sleepiness

Episodes of delirium

Irritability

Syncopal states Fatigue

Anorexia

Reduced level of activity

Gastrointestinal symptoms


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Complementary Investigations

Electrocardiogram -rhythm disturbances-bundle branch blocks-myocardial ischemia

Chest radiography -cardiomegaly- pulmonary congestion

- pulmonary hypertension

Doppler echocardiographyanatomical and functionalassessment

-quantify valvular lesions-pressure gradients-diameter of cardiac cavities-wall thickness-myocardial contractility-ventricular ejection fraction-ventricular relaxation


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Complementary InvestigationsExercise test (ET) assessing the functional capacity and

patients response to the treatment

6-minute-walk test -


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Treatment Non pharmacological

Appropriate diet Cessation of smoking

Increased physical activity

Immunization influenza and pneumococcus

Dietary sodium restriction

Alcohol reduction

Weight reduction in obese patients


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Treatment Pharmacological


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Treatment Diuretics

Controlling symptoms fluid retention is present inthe form of edema and pulmonary congestioncontrol of dyspnea and improves physical exercisetolerance

Loop diuretics are initially used

Thiazide diuretics should be added refractoriness toloop diuretics

Potassium sparing diuretics

spironolactone

control of potassium and creatinine


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Treatment digitalis

Some studies show that digitalis effective in controllingsymptoms and improving physical exercise tolerance

Digoxin is a first line drug for treating atrial fibrillationassociated with HF


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Treatment ACE inhibitors

ACE inhibitorsHF and systolic left ventriculardysfunction after myocardial infarction

Contraindicated

when serum potassium is above 5.5 mEq/L in the presence of

bilateral renal artery stenosis symptomatic hypotension

renal failure

previous history of angioedema with their use


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Treatment ACE inhibitors

Side effect Irritating dry cough

Hypotension

renal failure

Reduction or loss of taste occur Leading to loss of appetite


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Treatment ARBs

ARBsmainly indicated in patients with chronic HFand systolic ventricular dysfunction who have intoleranceto ACE inhibitors


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Treatment beta blockers

The combination of a beta-blocker and conventional therapywith diuretics, ACE inhibitors and digitalis leads to animprovement of symptoms, functional class and left

ventricular function

Beta blockers are contraindicated in

bradycardia advance atrioventricular block

hypotension with blood pressure below 90 mmHg

bronchospastic disease

decompensated HF.

Side effects asthenia,fatigue, sleep disturbance, peripheralvascular disorder, bradycardia and AVB


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Treatment direct vasodilators

The combination of isosorbide dinitrate and hydralazine treatment of HF is recommended for patients ondigitalis, diuretics and beta-blockers, that cannot tolerate

ACE inhibitors or ARBs

in presence of renal failure hyperkalemia (K > 5.5 meq/L)

worsening of glomerular filtration rate with serum creatinine > 2.5mg/dL


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Treatment anticoagulants

Indicated in patients with atrial fibrillation

history of thromboembolic events

left ventricular aneurysm

The use of subcutaneous unfractionated heparinpatients with decompensated HF and bedriddenprevention of pulmonary thromboembolism


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Resynchronizers

Ventricular resynchronization is indicated in patientswith advanced HF in functional class III or IV

ejection fraction less than or equal to 35%

a QRS complex equal to or greater than 0.12 seconds, associatedwith optimal pharmacological therapy

Resynchronization is not indicated in patients whosefunctional condition and life expectancy are limited bynoncardiac causes


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Diastolic heart failure (DHF)

DHF or HF with preserved systolic function has a highprevalence specially the elderly, women hypertensive, anddiabetics patients

Its diagnosis based on symptoms and signs of HF in

patients with normal ejection fraction in theechocardiogram.

The inclusion of the BNP measurementincrease thediagnostic accuracy


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general principles: Control of the heart frequency and arterial blood pressure

Reduction of the volume overload

Relief of myocardial ischemia.


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Drug therapy involves mainly the use of diureticsexcessive volume depletion and arterial hypotensionshould be carefully avoided in older patients moresensitive to preload reduction.

Calcium channel blockers, beta-blockers, ACE inhibitorsor ARBs and espironolactone relief of symptoms andreduce morbidity and mortality

Digitalis presence of atrial fibrillation with high

ventricular response.

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