GAGAL JANTUNG AKUT

ACUTE HEART FAILURE

dr. Jusdiono, SpJP, FIHA

GAGAL JANTUNG AKUTDEFINISINew onset or recurrence of gradual of rapidly worsening signs and symptoms of HF requiring urgent or emergency treatmentCepat : Disfungsi MendadakPreload - Afterload MismatchDapat terdapat pada pasien dengan/ tanpa kelainan jantung sebelumnya (Mis. Transfusi overload)3 KOMPONEN GJSymptomps: Cape / SesakSigns: Oedem / Ronchi / TachycardiaEvidence: Cardiomegaly / S3 Gallop / Murmur / EchoPATOFISIOLOGI 3 Fase:Fase InisiasiFase AmplifikasiFase Vicious Cycle

PATOFISIOLOGIFluid retentionCapillary interstitial fluid exchange ( pulmonary oedema)Myocardial pump performanceExtra cardiac pathologies

6 SUBSET KLINIS GJAADHF ( Acute on chronic )Hypertensive AHFPulmonary OedemaACS and HF ( Acute de novo )Cardiogenic ShockRight Heart FailureADHFEnvironmental: Excess salt and fluid (24%)Noncompliance with medication (24%)Adverse medication efforts (16%)CCBAntiaritmicNSAIDCorticosteroidsAlcohol

ADHFCardiovascular Acute Ischemia / InfarctionPulmonary EmbolismUncontrolled HypertensionAritmiaWorsening of valve disfunction, endocarditis

ADHFExtra Cardiac IllnessSepsis, Infection, HypoxiaRenal FailureThyroid DiseaseAnemia, Blood lossSleep apneaBilateral renal artery stenosis

HEMODYNAMIC SUBSETWarm and DryWarm and WetCold and DryCold and WetCardiac Index L/min/m22,218PCWP or LVEDPHEMODYNAMIC SUBSETWarm and DryWarm and WetCold and DryCold and WetCardiac Index L/min/m22,218PCWP or LVEDPOptimize Chronic TxHEMODYNAMIC SUBSETWarm and DryWarm and WetCold and DryCold and WetCardiac Index L/min/m22,218PCWP or LVEDPDiuretic +/Adjuvant TxHEMODYNAMIC SUBSETWarm and DryWarm and WetCold and DryCold and WetCardiac Index L/min/m22,218PCWP or LVEDPVasodilator+/ InotropesHEMODYNAMIC SUBSETWarm and DryWarm and WetCold and DryCold and WetCardiac Index L/min/m22,218PCWP or LVEDPDiuretic +/Vasodilator +/InotropesWETCardiacOutputPCWP or LVEDP18Symptoms :Shortness of breath,Pulmonary congestion,Peripheral edema,Jugular venous distentionVolume OverloadCardiac OutputPCWP or LVEDPCOLDCardiac Index L/min/m22,2SymptomsCold, Clammy extremities,Altered mental status CLASSIFICATION OF HEART FAILUREAmerican Heart Association ClassificationStage A: Patients are at high risk for heart failure but have not developed structural heart disease and have no symptomsStage B: Patients have developed structural heart disease have not (yet) developed symptomsStage C: Patients with past or current heart failure symptoms in association with structural damage to the heartStage D: Patients with end stage, or terminal heart failure requiring special treatment strategies

NEW YORK HEART ASSOCIATION CLASIFICATIONClassFunctional StateSymptomsINo limitationAsymptomatic during usual daily activityIISlight limitationMild symptoms (dyspnea, Fatique, or chest pain) with ordinary daily activityIIIModerate LimitationSymptoms noted with minimal activityIVSevere LimitationSymptoms arrestDIAGNOSTIC STUDIESBasic Laboratory testingScreening for cardiac enzymesB-Natriuretic PeptideECGChest X-RayEchocardiographyPulmonary artery catheterizationPeak flow / end tidal CO2

ESTABLISH THE DIAGNOSISPhysical :Vital sign: Hypertermi (sepsis), hypothermia (thyroid disease), Bradicardia ( AV block, Hyperkalemia, drug, severe hypoxia)Signs of congestion : jugular venous distention, abdominal jugular reflux, audible 3rd heart soundPulmonary , leg examVASODILATORSVasodilatorsDosingSEOtherNTG10 20 mg/min200 mg/minHypotensionHeadache

Tolerance or continuous useISDN1 mg/hour10 mg/hourHypotensionHeadacheTolerence or continuous useNitroprusside0,3 mg/kg/min5 mg/kg/minHypotensionIsocyanate ToxicityLight SensitiveINOTROPESShort term inotropic support maintain systemic perfusion and preserve end-organ performanceDeleterious effect upon patients with preserved or moderately depressed ventricular function and congestionNot demonstrated improved outcomesINOTROPESDebutamine: 2-20 mg/kg/minDopamin: 5 mg/kg/min: Vasopressor effectVASSOPRESSORSNorepinephrine: - No bolus - 0,2 1,0 mg/kg/minEpinephrine: - Bolus 1mg can be given I.V during resuscitation, repeated every 3-5 min - 0,05 0,5 mg/kg/min

RESPIRATORY THERAPYCPAP improvesLung mechanics : recruiting Atelectatic alveoli, Improving pulmonary compliance, reducing work of breathingHemodynamics : reducing preload and afterloadRecommends acute cardiogenic pulmonary edemaStart at 10 15 CmH2OMechanical Circulatory SupportRenal Replacement TherapyIABP ( Intra Aortic Ballon Pump )Extracorporeal ventricular assist devicesECMO ( Extra Corporeal Membrane Oxygenation)

DRUG FOR HEART FAILUREProven morbidity and mortality benefitB BlockerACE InhibitorsARBAldosterone AntagonistISDN HydralazineDRUG FOR HEART FAILUREImproved symptoms and no prove mortality benefitDigoxinNexiritideI.V VasodilatorsInotropic AgentsTherapy for Heart DiseaseMechanical Support DevicesCRT (cardiac resynchronization therapy )VADs ( Ventricular Assist Devices)