ABC of Heart Failure Acute AndChronic Management Strategies

7/27/2019 ABC of Heart Failure Acute AndChronic Management Strategies

1/24

ABC of heart failureAcute and chronic management strategies

T M il lane, G Jackson, C R Gibbs, G Y H L ip

BMJ Volume 320, 26 February 200


2/24

Strategis penanganan gagal jantung akut dan kronis:

- perbaiki gejala klinis dan prognosis Penanganan tergantung pada etiologi dan beratnya kondisi

pasien, sehingga intervensi yang tepat dapat memperbaiki

prognosis

Survival rates (%) compared with chronic heart failure

At 1 year At 2 years At 3 years

Breast cancer 88 80 72

Prostate cancer 75 64 55

Colon cancer 56 48 42

Heart failure 67 41 24


3/24

Penanganan Gagal Jantung Akut(GJA)

Pemeriksaan

GK : ansietas, takikardi dan dispnu

Syok kardiogenik : muka pucat, hipotensi (TDS < 90 mmHg)oliguria dan Cardiak Output (CO) rendah

Gagal jantung berat dan syok kardiogenik bisa terjadi pada :

Infark miokard luas, Aritmia kordis berkepanjangan (AF,VT),

problem mekanis (ruptur m. papilaris akut, post infark VSD)


4/24

Chest x ray film in patient with acute pulmonary oedema


5/24

Gagal jantung yang berat : Kasus emergensi

- perlu penanganan efektif

- perlu pemeriksaan untuk mengetahui penyebab,

memperbaiki status hemodinamik, mengatasi bendungan paru,

memperbaiki oksigenasi jaringan

- Pemeriksaan klinis dan radiologis

severity dan prognosis

- Klasif ikasi Kil l ip :menilai severity GJA dan GJK

Killip classification

Class Clinical features Hospital mortality (%)

Class I No signs of left ventricular dysfunction 6

Class II S3 gallop with or without mild to 30

moderate pulmonary congestion

Class III Acute severe pulmonary oedema 40

Class IV Shock syndrome 80 - 90


6/24

Pengobatan

posisipasien duduk tegak lurus,

oksigen konsentrasi tinggi (face mask)

observasi ketat monitor di ICCU

perlu kateterisasi urine balance cairan

periksa AGDA (oksigenasi dan keseimbangan asam basa)

- Base Excess (BE) panduan untuk perfusi jaringan

- Bila BE lebih negatif pada GJA asidosis laktat akibat

metabolisme anaerob (prognostik buruk) Infus Bikarbonat (kasus refrakter)


7/24

Loop diuretik IV : frusemide (furosemide)

venodilatasi sementara

diberikan pada pasien udem pulmonum

meningkatkan produksi vasodilator prostaglandin di renal

(perbaikan simptomatis dan diuresis)

NSAID dihindari (inhibitor prostaglandin)

Opiat atau opioid parenteral (morphine atau diamorphine) menghilangkan ansietas, nyeri dan disstres

menurunkan kebutuhan oksigen miokardial

menimbulkan venodilatasi

menurunkan preload, tekanan pengisian jantung dankongesti paru


8/24

Nitrat (sublingual, buccal dan IV)

menurunkan tekanan preload dan tekanan pengisian jantung

berguna pada angina dan gagal jantung

Sodium nitroprusside : vasodilator yang bekerja langsung

dan kuat (kasus GJA refrakter)

Sit patient upright

High dose oxygen

Intravenous loop diuretics

Intravenous opiates/opioids

(morphine/diamorphine)

Intravenous, buccal, or

Sublingual nitrates

Corrects hypoxia

Cause venodilatation and diuresis

Reduce anxiety and preload

(venodilatation)

Reduce preload and afterload ischaemia

And pulmonary artery pressures

Basic measures

Initial drug treatment

Acute heart failure ; basic measures and initial drug treatment


9/24

Dukungan inotropik jangka pendek

Pada GJA refrakter yang berat dimana CO rendah, dipakai

obat inotropik(Dobutamin dan Dopamin) bekerja sebagai inotropik positif

bekerja di reseptor1 otot jantung

meningkatkan aritmia kordis

Inhibitor phosphodiesterase (enoxamine) : kurang bermanfaat

dan meningkatkan mortalitasAminophylline IV jarang digunakan


10/24

Inotropes ; agonists

(dobutamine)

Dopamine (low dose)

Inotropes ; phosphodiesterase

Inhibitors (enoximone)

Intravenous aminophylline

Assisted ventilation

Circulatory assist devices

Increase myocardial contractility

Increases renal perfusion, sodium

Excretion, and urine flow

Increase myocardial contractility and

venodilatation

Weak inotropic effect, diuretic effect,

Bronchodilating effect

Reduces myocardial oxygen demand;

Improves alveolar ventilation

Give mechanical support

Second line drug treatment

Advanced management

Acute heart failure; second line drug treatment and advanced management

Intravenous inotropes and circulatory assist devices

Short term support with intravenous inotropes or circulatory assist devices, or with both,

may temporarily improve haemodynamic status and peripheral perfusion

Such support can act as a bridge to corrective valve surgery or cardiac transplantation in

acute and chronic heart failure


11/24

Gagal Jantung Kronik (GJK)

GJK dapat kompensata atau dekompensata

Gagal jantung kompensata :GK stabil, retensi cairandan tidakdijumpai udem pulmonum

GK dekompensata : udem pulmonum, letargi, malaise,menurunnya kemampuan kerja dan sesak nafas saat beraktifitas

Penyebab dekompensata :iskemia, aritmia, infeksi dangangguan elektrolit

sering terjadi atrial fibrilasi

Penanganan bertujuan untuk :

1. Memperbaiki GK, meningkatkan kualitas hidup

2. Meningkatkan prognosis dan menurunkan perawatan RS


12/24

Penanganan Awal

Pendekatan non farmakologis dan perubahan gaya hidup

Loop diuretik(bila overload cairan), selain restriksi garam

dan mencegah retensi cairan

ACE inhibitor(pada stadium awal bila tidak ada kontraindikasi)AIIRAbila tak tahan dengan ACE inhibitor

bloker (carvedilol, bisoprolol, metoprolol) diberikan pada

pasien stabil dengan dosis rendah dan dinaikkan secara titrasi

dibawah pengawasan spesialist

Digoxin oral, pada pasien disfungsi sistolik ventrikel kiri yangtidak ada perbaikan dengan diuretik dan ACE inhibitor optimal

Warfarin diberikan pada pasien atrial fibrilasi


13/24


14/24

Management of chronic heart failure

General advice

Counselingabout symptoms and compliance

Social activity and employment

Vaccination (influenza, pneumococcal)

ContraceptionGeneral measures

Diet (for example, reduce salt and fluid intake)

Stop smoking

Reduce alcohol intake

Take exercise

Treatment optionspharmacological

Diuretics (loop and thiazide)Angiotensin converting enzyme inhibitors

Blockers

Digoxin

Spironolactone

Vasodilators (hydralazine / nitrates)

Anticoagulation

Antiarrhythmic agents

Positive inotropic agentsTreatment optionsdevices and surgery

Revascularisation ( PTCA and CABG )

Valve replacement ( or repair )

Pacemaker or implantable cardiodefibrillator

Ventricular assist devices

Heart transplantation


15/24

Treatment of left ventricular systolic dysfunction

Confirm diagnosis by echocardiography

If possible, discontinue aggravating drugs (eg NSAID)

Address non-pharmacological and lifestyle measures

Add loop diuretic (eg frusemide)

ACE inhibitor

Consider blocker* in patients with chronic, stable condition

ACE inhibitor

Persisting clinical features of heart failure

Options Optimise dose of loop diuretic

Low dose spironolactone (25 mg once a day)

Digoxin Combine loop and thiazide diuretics

Oral nitrates / hydralazine

Atrial fibrillation Angina

Options Digoxin Options blocker

blocker (if not already given)

(if not already given) Oral nitrates Warfarin Calcium antagonist

(eg amlodipin)

Consider specialist referral in patient with atrial fibrillation (electrical cardioversion or

Other antiarhythmia agents (eg amiodarone may be indicated),angina (coronary

Angiography and revascularisation nay be indicated), or persistent or severe symptoms

In the United Kingdom carvedilol is used

for mild to moderate symptoms and bisoprolol

for moderate to severe congestive heart failure

Example of management algorithm for left ventricular dysfunction

* Initial low dose (eg carvedilol, bisoprolol, metoprolol) with cautious titration under expert supervision

Symptomatic Asymptomatic


16/24

Supervised exercise programmes are of proved benefit, and regular

exercise should be encouraged in patients with chronic stable heart failure Weighing the patient daily is valuable in monitoring the response to

treatment

Education, counselling, and support

A role is emerging for heart failure liaison nurses in educting and

supporting patients and their families, promoting long term compliance,

and supervising treatment changes in the community

Depression is common, underdiagnosed, and often undertreated;

counselling is therefore importantfor patients and families,

and the newer antidepressants ( particularly the selective serotonin

reuptake inhibitors ) seem to be well tolerated and are usefull in selected

patients


17/24

Tindakan khusus

Pompa Balon Intra-aorta dan Peralatan mekanis

Intra-aortic ballon couterpulsation dan alat bantu ventrikel kiri

digunakan sebelum dilakukan operasi koreksi katup jantung,

transplantasi jantung atau CABG

Alat mekanis diindikasikan bila :

a). Terdapat kemungkinan perbaikan spontan (kardiomiopati

peripartum

b). Sebelum dilakukan operasi jantung (ruptur m. papilarismitral, post infark VSD )

c). Transplantasi jantung


18/24

Indications and contraindications to cardiac transplantasion in adult

IndicationsEnd stage heart failure for example, ischaemic heart disease and dilated

cardiomyopathy

Rarely, restrictive cardiomyopathy and peripartum cardiomyopathy

Congenital heart disease (often combined heart-lung transplantation required)

Absolute contraindications

Recent malignancy (other than basal cell and squamous cell carcinoma of the skin)

Active infections (including HIV, Hepatitis B, Hepatitis C with liver disease)

Systemic disease which is likely to affect life expectancy

Significant pulmonary vascular resistance

Relative contraindications

Recent pulmonary embolism

Symptomatic peripheral vascular disease

ObesitySevere renal impairment

Psychosocial problemsfor example, lack of social support, poor compliance,

psychiatric illness

Age (over 6065 years)


19/24

Left ventricular assist device


20/24

Strategi revaskularisasi dan operasi lainnya

Perburukan fungsi ventrikel kiri belum kontra indikasi absolut

operasi jantung, walau akan meningkatkan resiko

Penyakit jantung iskemik ; penyebab tersering GJK di Inggris dipertimbangkan CABG atau PTCA

Koreksi penyakit katup paling sering pada stenosis aorta, stenosis

mitral dan penutupan VSD akut

Operasi lainnya seperti aneurisectomy dan operasi Batista


21/24

Transplantasi jantung

Transplantasi jantung dapat meningkatkan survival rate dan

kualitas hidup

Kebutuhan akan transplantasi organ telah meningkat, tetapi

jumlah operasi transplantasi tetap stabil karena terbatasnyaorgan

Dengan adanya transplantasi jantung, mortalitas < 10%,

survival rate 1,5,10 tahun : 92%, 75%, 60% lebih baik

dibandingkan dengan obat-obatan (angka mortalitas 1 tahun30% - 50% pada gagal jantung


22/24

Number of heart transplantations worldwide and mean age of donors


23/24

Survival jangka panjang transplantasi manusia dipengaruhi

oleh kecepatan terjadinya aterosklerosis padagraft, yang

terjadi diawal tiga bulan setelah operasi

Obat anti- rejeksi yang sering dipakai : cyclosporin dan obat

imunosupresant lainnya

Dari Eurotransplant database (1990-5) : 25% pasien

meninggal saat menunggu donor, hanya 60% yang menerima

transplantasi dalam jangka 2 tahun (rata-rata 12 bulan)


24/24

ABC of Heart Failure Acute AndChronic Management Strategies

Documents

Transcript of ABC of Heart Failure Acute AndChronic Management Strategies