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)