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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

Definisi Gagal Jantung

supply unequal with demand

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.

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

c. Blood volume : - low output: Myocardial Infarction, MR, AS - high output: Anemia, Hyperthyroid

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%.

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.

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

Diagnosis

Gold standard ? "Framingham criteria, the "Boston criteria, the "Duke criteria and (in the setting of acute myocardial infarction) the killip class

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

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

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

NYHA (New York Heart Association)


Class % of Symptoms patients
35% No symptoms or limitations in ordinary physical activity Mild symptoms and slight limitation during ordinary activity Marked limitation in activity even during minimal activity. Comfortable only at rest Severe limitation. Experiences symptoms even at rest

II

35%

III

25%

IV

5%

Imaging

Chest X-rays : Kerley lines, cuffing of the areas

Echocardiography : EF 50-80%

Electrophysiology

Arrhythmias Ischemic heart disease Right and left ventricular hypertrophy presence of conduction delay or abnormalities (e.g. left bundle branch block)

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

Angiography

Management
1 Diet and lifestyle measures

1.1 Fluid restriction 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

2 Pharmacological management

3 Devices : EF <35% CRT 4 Surgery : CABG, Heart transplant

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