Gagal JantungPendekatan Berdasarkan Bukti

(Evidence-based)

Hardjo PrawiraJAKARTA, 25 AGUSTUS 2019

KASUS

• Seorang laki-laki 45 tahun.• Keluhan utama: sesak nafas bila aktivitas sejak 3 bln. Dua hari

terakhir sering terbangun tengah malam krn sesak dan tidur dgn 2 bantal.• Riwayat penyakit hipertensi 3 thn dan berobat tdk teratur. Merokok

sekitar 1 bungkus per hari• Pemeriksaan fisik: TD=150/100, N=120x/mnt, JVP meningkat,

Cor=gallop +, Pulmo=ronchi basah basal +, Abd= hepar 2 jari, Extr= edema +. • Pem Penunjang: foto toraks=kardiomegali, EKG= sinus takikardi dgn

gambaran LVH dan iskemia

TATALAKSANA ???

Bagian I:Epidemiologi, Etiologi dan Patofisiologi Gagal

Jantung

Definisi Gagal Jantung:

Suatu sindroma klinis dimana jantung tidak dapat mempertahankan curah jantung yang cukup untuk memenuhi metabolisme tubuh

The Donkey Analogy

Gangguan fungsi ventrikel membatasi kemampuan pasien untuk melakukan aktivitas sehari-hari

1 World Health Statistics, World Health Organization, 1995.2 American Heart Association, 2002 Heart and Stroke Statistical Update.

Insidens dan Prevalensi Gagal Jantung

• Prevalensi • Worldwide, 22 juta1

• United States, 5 juta2

• Insidens• Worldwide, 2 juta kasus baru per tahun• United States, 500,000 kasus baru per tahun

• Gagal jantung menyerang 10 org di antara 1000 orang di US

Prevalensi Gagal Jantung (Umur dan Kelamin)

United States: 1988-94

0

2

4

6

8

10

Percent of Population

20-24 25-34 35-44 45-54 55-64 65-74 75+

MalesFemales

Source: NHANES III (1988-94), CDC/NCHS and the American Heart Association

New York Heart Association Functional Classification

Class I: Aktivitas biasa tdk menimbulkan gejala

Class II: Hambatan ringan pada aktivitas fisik. Nyaman saat istirahat, tapi aktivitas fisik biasa menimbulkan lelah, sesak, berdebar, atau angina

Class III: Hambatan aktivitas fisik yg jelas. Nyaman saat istirahat, tapi aktivitas fisik lebih ringan dari biasa menimbulkan lelah, sesak, palpitasi, dan angina

Class IV: Aktivitas fisik yang sangat ringan pun tidak dapat dilakukan. Gejala gagal jantung timbul saat istirahat

MERIT-HF Study Group. Effect of Metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL randomized intervention trial in congestive heart failure (MERIT-HF). LANCET. 1999;353:2001-07.

Severity of Heart FailureModes of Death

12%

24%

64%

CHF

Other

SuddenDeath

n = 103

NYHA II

26%

15%

59%

CHF

Other

SuddenDeathn = 103

NYHA III

56%

11%

33%

CHF

Other

SuddenDeath

n = 27

NYHA IV

KLASIFIKASI GAGAL JANTUNG

• Akut • Kronis• Sistolik• Diastolik• Kanan• Kiri• Kongestif• Forward• Backward• High Output

30%

70%

Diastolic DysfunctionSystolic Dysfunction

(EF < 40%)(EF > 40 %)

Gangguan fungsi ventrikel kiri:

• Sistolik: penurunan kontraktilitas/kemampuan ejeksi• Sekitar 2/3 penderita gagal jantung1

• Diastolik: gangguan pengisian/relaksasi

1 Lilly, L. Pathophysiology of Heart Disease. Second Edition p 200

Cardiac Output = Curah Jantung

• Cardiac output= jumlah darah yang dipompa oleh jantung setiap menit

Cardiac Output = HR x SV

HR= heart rate/laju nadi

SV= stroke volume/volume sekuncup

StrokeVolume

Preload Afterload

Contractility

Cardiac Output

Heart Rate• Synergistic LV Contraction•Wall Integrity• Valvular Competence

Penentu Fungsi Ventrikel:

Volume Overload

Pressure Overload

Loss of Myocardium

Impaired Contractility

LV DysfunctionEF < 40%

¯ CardiacOutput

Hypoperfusion

­ End Systolic Volume

­ End Diastolic Volume

Pulmonary Congestion

Disfungsi Ventrikel Kiri

Hemodinamik Gejala Gagal Jantung

Hemodynamic Basis forHeart Failure Symptoms

LVEDP=left ventricular end-diastolic pressure ­

Left Atrial Pressure ­

Pulmonary Capillary Pressure ­

Pulmonary Congestion

Gangguan Fungsi Ventrikel Kiri: Sistolik dan Diastolik

•Gejala:• Sesak saat aktivitas

• Paroxysmal Nocturnal Dyspnea

• Takikardia/palpitasi

• Batuk

• Hemoptysis

• Tanda:• Ronkhi basah basal

• Edema Paru

• S3 Gallop

• Effusi pleura

• Respirasi Cheyne-Stokes

Gagal Jantung Kanan:

•Gejala:• Nyeri abdomen

• Anorexia

• Nausea

• Kembung

• Edema

• Tanda:- Edema perifer

• Jugular Venous Distention

• Abdominal-Jugular Reflux

• Hepatomegali

Mekanisme Kompensasi

• Mekanisme Frank-Starling

• Aktivasi Sistem Neurohormonal

• Remodeling Ventrikel

Compensatory Mechanisms

Frank-Starling Mechanism

a. At rest, no HF

b. HF due to LV systolic dysfunction

c. Advanced HF

Compensatory Mechanisms

Neurohormonal Activation

Many different hormone systems are involved in maintaining normal cardiovascular homeostasis, including:

• Sympathetic nervous system (SNS)

• Renin-angiotensin-aldosterone system (RAAS)

• Vasopressin ( antidiuretic hormone, ADH)

­MAP = (­SV x ­HR) x ­TPR

Sympathetic Nervous System

­ Contractility Tachycardia Vasoconstriction

Compensatory Mechanisms: Sympathetic Nervous System

Decreased MAP (Mean Arterial Pressure)

Packer. Progr Cardiovasc Dis. 1998;39(suppl I):39-52.

­ CNS sympathetic outflow

Disease progression

­ Cardiac sympatheticactivity

b1-receptors

b2-receptors

a1-receptors

VasoconstrictionSodium retention

Myocardial toxicityIncreased arrhythmias

­ Sympatheticactivity to kidneys

+ peripheral vasculature

Activationof RAS

a1- b1-

Sympathetic Activation in Heart Failure

Adverse Effect of Sympathetic Activation in Heart Failure

•Dysfunction and Death of Cardiac Myocytes•Provocation of Myocardial Ischaemia•Provocation of Arrhythmias•Increase in Heart Rate

­MAP = (­SV x ­HR) x ­TPR

Renin-Angiotensin-Aldosterone(¯ renal perfusion)

Salt-water retentionThirst

Sympatheticaugmentation Vasoconstriction

Compensatory Mechanisms: Renin-Angiotensin-Aldosterone (RAAS)

LV Dysfunction

Decreased cardiac outputand

Decreased blood pressure

Frank-Starling MechanismRemodeling

Neurohormonal activation

Increased cardiac output (via increasedcontractility and heart rate)

Increased blood pressure (via vasoconstrictionand increased blood volume)

Increased cardiac workload(increased preload and afterload)

Lingkaran Setan Gagal Jantung

Bagian II Penilaian Gagal Jantung

Penilaian pada Gagal Jantung

•Riwayat Penyakit

•Pemeriksaan Fisik

•Laboratorium dan penunjang diagnostik lainnya

Evaluasi Diagnostik Gagal Jantung:

• Tentukan Jenis Gagal Jantung

(systolic vs. diastolic)

• Tentukan Etiologi

• Tentukan prognosis

• Tentukan terapi

ELEKTROKARDIOGRAM

FOTO TORAKS

M-Mode Echo 2D Echo

RALA

RVLV

Septum

LV cavity

LV Wall

ECHOCARDIOGRAPHY

Bagian III: Tatalaksana

Lingkaran Setan Tatalaksana Gagal Jantung

Chronic HF

MD’s Office

Emergency Room

Hospitalization

SOB

­ Weight

PO LasixIV Lasix or Admit

Diurese & Home

Tatalaksana Umum

Modifikasi Gaya Hidup:

•Mengurangi berat badan

• Berhenti merokok

• Hindari alkohol

• Latihan

Obati penyakit dasar:• Obati hipertensi, tiroid, kelainan

katup, hyperlipidemia, diabetes, aritmia• Revaskularisasi koroner

Treatment Options for HF:

• Pharmacological:ACE inhibitors , ARB, SacubitrilDiureticsDigitalisNitrates/HydralazineSpironolactoneB-blockers• Non-pharmacological

Life-style modificationCardiac Resynchronization TherapyLeft-ventricular assist deviceHeart Transplant

Strategi Pencegahan dan Tatalaksana Dini

Heart Failure Continuum

HT

Coronary Risk Factor

Remodelling

Symptoms Decreased Tissue Perfusion

IncreasedHospitalisation Death

LV Dysfunction

Heart Failure

LVH MI

CAD

Diastolic Systolic

Strategi Tatalaksana yg Umum

Stage A

At high risk, no structural disease

Stage B

Structural heart disease,

asymptomatic

Stage D

Refractory HF requiring

specialized interventions

Therapy

• Treat Hypertension

• Treat lipid disorders

• Encourage regular exercise

• Discourage alcohol intake

• ACE inhibition

Therapy

• All measures under stage A

• ACE inhibitors in appropriate patients

• Beta-blockers in appropriate patients

Therapy

• All measures under stage A

Drugs:

• Diuretics

• ACE inhibitors

• Beta-blockers

• Digitalis

• Dietary salt restriction

Therapy

• All measures under stages A,B, and C

• Mechanical assist devices

• Heart transplantation

• Continuous (not intermittent) IV inotropic infusions for palliation

• Hospice care

Stage C

Structural heart disease with prior/current

symptoms of HF

Hunt, SA, et al ACC/AHA Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult, 2001

Cardiac Resynchronization Therapy

Increase the donkey’s (heart) efficiency

Summary

• Heart failure is a chronic, progressive disease that is generally not curable, but treatable

•Most recent guidelines promote lifestyle modifications and medical management with ACE inhibitors, beta blockers, digoxin, and diuretics

• It is estimated 15% of all heart failure patients may be candidates for cardiac resynchronization therapy

• Close follow-up of the heart failure patient is essential, with necessary adjustments in medical management

Take-home Message:

• Gagal Jantung dapat dicegah dgn tatalaksana faktor risiko yang agressif• Terapi optimal gagal jantung:

ACEIB-blockerAldosterone antagonistDiuretikDigitalis (indikasi tertentu)