Penanganan Gagal Jantung Pada Pelayanan Primer ( Dr. Todung )
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Transcript of Penanganan Gagal Jantung Pada Pelayanan Primer ( Dr. Todung )
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PENANGANAN GAGAL
JANTUNG PADA PELAYANAN
PRIMER
Dr.TODUNG D.A.SILALAHI SpPD,K-KV,FINASIM
CARDIOVASCULAR DIVISION
DEPARTEMENT OF INTERNAL MEDICINE UKRIDA
2013
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Definisi Gagal Jantung
supply unequal with demand
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Epidemiologi
Gagal jantung mempengaruhi >20
juta pasien di dunia
Meningkat seiring pertambahan usia,
dan mengenai pasien usia lebih dari
65 tahun sekitar 6-10%
laki-laki > wanita.
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Classification
a. Location:
left-side heart failure, right side heart failure
or biventricular.
b. Function :
- Sistolic (contraction) : MI, Cardiomyopathy
- Diastolic function (relaxtation or filling) :
valve MS, LVH
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c. Blood volume :
- low output: Myocardial Infarction, MR, AS
- high output: Anemia, Hyperthyroid
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Chronic heart failure
In the United States (the National Health and Nutrition Examination Survey
(NHANES I) found the following causes ranked by Population Attributable
Risk score
Ischaemic heart disease 62% ,Cigarette smoking 16%
Hypertension (high blood pressure) 10%, Obesity 8%, Diabetes 3%
Valvular heart disease2% (much higher in older populations).
An Italian registry of over 6200 patients with heart failure showed the following
underlying causes:
Ischaemic heart disease 40%
Dilated cardiomyopathy 32%
Valvular heart disease 12%
Hypertension 11% Other 5%.
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Acute decompensation
Chronic stable heart failure may easily decompensate
, This most commonly results from an intercurrent illness
(such as pneumonia), myocardial infarction (a heart
attack), arrhythmias, uncontrolled hypertension, or a
patient's failure to maintain a fluid restriction, diet, or
medication. Other well recognized precipitating
factors include anemia and hyperthyroidism which
place additional strain on the heart muscle.
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Signs and symptoms
Dyspnea
Fatigue
Diaphoresis
Paroxysmal nocturnal dyspnea
Chest pain as the initial complaint
Swelling in the legs
Discomfort in the upper abdomen the right
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Diagnosis
Gold standard ?
"Framingham criteria”, the "Boston criteria“, the
"Duke criteria“ and (in the setting of acute
myocardial infarction) the killip class
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Framingham criteria
requires the simultaneous presence of
at least 2 of the following major
criteria
1 major criterion in conjunction with 2
of the following minor criteria
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Major criteria:
Cardiomegaly on chest radiography
S3 gallop a third heart sound
Acute pulmonary edema
Paroxysmal nocturnal dyspnea
Crackles on lung auscultation
Central venous pressure of more than 16 cm
H2O at the right atrium
Jugular vein distension
Positive abdominojugular test
Weight loss of more than 4.5 kg in 5 days in response to
treatment (sometimes classified as a minor criterium
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Minor criteria
Tachycardia of more than 120 beats per minute
Nocturnal cough
Dyspnea on ordinary exertion
Pleural effusion
Decrease in vital capacity by one third from
maximum recorded
Hepatomegaly
Bilateral ankle edema
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NYHA (New York Heart Association)
Class % of
patients
Symptoms
I 35% No symptoms or limitations in ordinary physical
activity
II 35% Mild symptoms and slight limitation during
ordinary activity
III 25% Marked limitation in activity even during minimal
activity. Comfortable only at rest
IV 5% Severe limitation. Experiences symptoms even at
rest
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Imaging
Chest X-rays : Kerley lines, cuffing of the areas
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Echocardiography : EF 50-80%
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Electrophysiology
Arrhythmias
Ischemic heart disease
Right and left ventricular hypertrophy
presence of conduction delay or abnormalities
(e.g. left bundle branch block)
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Blood tests
electrolytes (sodium, potassium)
measures of renal function, liver function
tests, thyroid function tests, a complete blood count,
and often C-reactive protein if infection is
suspected.
An elevated B-type natriuretic peptide (BNP) is a
specific test indicative of heart failure, with
a sensitivity of 85% and specificity of 84% in
detecting heart failure
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Angiography
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Management
1 Diet and lifestyle measures
1.1 Fluid restriction
2 Pharmacological management
2.1 Angiotensin-modulating agents : ACE inhibitor
2.2 Diuretics : Furosemide, HCT, Spironolactone
2.3 Beta blockers : bisoprolol
2.4 Positive inotropes: digoxin
2.5 Alternative vasodilators :ISDN, Hydralazine
2.6 Aldosterone receptor antagonists :spironolactone
2.7 Recombinant neuroendocrine hormones :Nesiritide
2.8 Vasopressin receptor antagonists :Tolvaptan
3 Devices : EF <35% CRT
4 Surgery : CABG, Heart transplant
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