Beruflich Dokumente
Kultur Dokumente
Kariadi Semarang
Sumber : a) BPS Sensus Penduduk Indonesia tahun 1971, 1980 dan 1990 b) BPS Survey Antar Sensus Penduduk 1985 c) LD-FEUI, Proyeksi Penduduk Indonesia 1990 - 2020
16.0
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0 1971 1980 1985 1990 1995 2000 2005 2010 2015 2020
Definition
CHF is a complex clinical syndrome caharacterized by dysfunction of the left-right or both ventricles and changes in neurohumoral regulation This syndrome consist of : Exercise intolerance Disrythmia LV-RV Dysfunction Fluid Retention : Pretibial Edema, Ascites, Pulmonary Edema
Sudden death
Arrhythmia & Loss of muscle
Myocardial ischemia
Remodeling
CAD
ANG II
Ventricular dilatation
Atherosclerosis LVH
Heart failure
EPIDEMIOLOGY
Morbidity and Mortality rates remain high. USA : estimated more than 2 million patient. 400.000 new patient each year. 900.000 required hospitalization. 200.000 patient die/year. Annual mortality rate : 40-50% in NYHA Class IV
Males Females
50 40 30 20 10 0
45-54
55-64
65-74
75-84
85-94
Age (yr)
100
Progression Mechanism of death Sudden death 40% Worsening CHF 40% Other 20%
Patients surviving %
Annual mortality 0
<5%
Asymptomatic
10%
Mild
20 to 30%
Moderate
30 to 80%
Severe
Aging: The Major Risk Factor for Cardiovascular Morbidity and Mortality
STROKE STROKE
Disease
Co
tro ph y
ro
Increasing Age
normal Aging
Prevention Stage
Ce Va ll sc Ch u an l ar ge s
At he ro sc
LV
Hy
pe
LV RESERVE
Increasing Age
Hy pe r
si en rt
sc h
em i
l e E ar r o ly tic Le s i ons
on
na r
yI
li c Systo
V L Ma ss
e Pr e ur ss
t ys S
ic ol
Myocardial Disease
Myocyte Loss
Aging
Neurohormonal Activation
Peak E velocity
Peak A velocity S2
VRT
DT
Time
Abbreviations and explanation. S2 = second heart sound. E velocity = peak mitral flow velocity of early rapid ventricular filling. A velocity = peak mitral flow velocity of late ventricular filling (atrial systolic). DT = deceleration time ie. The interval from closure of aortic valve to opening of mitral valve (this parallels deceleration time). E/A = early filling/late filling of the left ventricle. PVs = pulmonary venous flow velocity in systole. PVd = pulmonary venous flow velocity in diastole.
Age > 60 years Male gender Prior myocardial infarction Alcoholism Valvular insufficiency Progressive shortness of breath Normotensive or hypotensive Jugular venous distension Displaced PMI* S3 gallop Q-waves, prior myocardial infarction Marked cardiomegaly
Age > 70 years Female gender Chronic hypertension Renal disease Obesity Aortic stenosis Acute pulmonary edema Atrial fibrillation Hypertensive Absence of jugular venous distension Sustained PMI* S4 gallop Left ventricular hypertrophy Normal or midly increased heart size
Management Outline
To make sure that patient has HF Ascertain Clinical features Etiology of HF NYHA Class/ Staging Concomitant disease Estimate Prognosis Anticipate complication Family Councelling(Exp On the Elderly pts) Appropriate management & Monitor progress
Non Pharmacologic
General Advice & Measure Information about simptom & Sign of HF ,MedicationUsed,Encouraged for daily & social activity. Vaccination against Influenza is adviced
DIURETICS
Essential for symptomatic treatment when fluid overload is present & manifest Short term: Reduction pulmonary congeston,JVP,Peripheral edema,BW. Intermediate:ImprovedSymptoms,Exercise tolerance ,Not proven reduced morbidity & mortality(Long term) Use combination with ACE Inh,BB,Digoxin
Hydralazine + ISDN
Indication: Intolerance ACE/ARBs Nitrates: Angina,EdemaPulmonum,or concomitant hypertension .
Beta-Blocking Agent
Recommended for the treatment of all pts with stable,All Stage HF already on standard treatment,unless Contra indicated. BB & ACE Inh should be used in Post MI pts regardless of EF with/No HF simptom. Bisoprolol,Metoprolol XL,Carvedilol are proven in reductionTotalmortality,Sudden death,Death to progression of HF. Reduced Hospitalization & Less worseningHF.
DIGITALIS
Recommended to improve clinical status decreased the risk of hospitalization without an impact on survival. Indicated in AF(Rate Controle) & Sinus Rhytm in Persisting HF despite ACE Inh& Diuretics Used Low-Dose
CONCLUSION
The spesific pathophysiologic that cause clinical disordered are superimposed on heart that are modified by aging. Diagnosis of CV diseases is delayed because of atypical symptoms. The incidenced of HF doubled with each decade of life & CHF is the leading caused of mortality and hospitalization.
The general management of HF on the elderly can be applied. Education of the patient and family may play significant role in reducing hospitaliza tion and mortality. Pharmacological therapy need close observation about side effect of the drug and used simple dosing to increase compliance.
Symptoms Persist
Persisting Fluid Retention Consider : combination of oral diuretics such as loop diuretic with : thiazine or metalazone spironolactone Consider : Intravenous diuretic
* Some physicians use digoxin as first line therapy for heart failure, with diuretics and ACE inhibitors, whereas others reserve its use to those patients with atrial fibrillation or those patients whose symptoms persist. (WHO, 1995)