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FAILURE
OLEH:
Gusti Ayu Temi V.
Melyana
Narasumber:
dr. Daniel Tobing, SpJP (K)
Outline
Introduction
Terminology
Definition
Classification
Precipitating factors
Pathophysiology
Clinical profiles
Sign and symptoms
Clinical presentation
Diagnosis
Management
Case ilustration
Introduction
Acute heart failure is among the most common causes for
hospitalization in patients >65 y.o in the developed world
Hypertensive AHF
Acutely
Decompensated
Chronic HF
PULMONARY
OEDEMA
ACS and
HF
Right HF
Cardiogenic
shock
ACS and HF
many patients with AHF present with a clinical picture and
laboratory evidence of an ACS.
Approximately 15% of patients with an ACS have signs and
symptoms of HF.
Episodes of acute HF are frequently associated with or precipitated
by an arrhythmia (bradycardia, AF, VT).
ESC Guidelines 2008
Diagnosis
Needs to be started in the pre-hospital setting and
continued in the emergency department
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
Laboratory test
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
Laboratory test : cont
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
Chest X Ray
In chronic HF usually
demonstrates increased
heart size , but
cardiomegaly sometimes
absent in acute HF
Progression of pulmonary
congestion:
first: Cephalization
second : Interstitial
edema
third: Pulmonary
(alveolar) edema
Echocardiography
Evaluate:
Chamber dimension
Valvular structure
Ventricular function
global & regional
Mechanical
complicating AMI
Pericardial pathology
Management of Acute
Heart Failure
Goal of Treatment
In
Acute Heart
Failure
No A B
Warm & dry Warm & wet
L
Right heart failure
Dehydration Fluid loading
C
Yes
Excessive diuretics Inotropic
ADHF
No A B
Acute pulmonary
edema
Hypertensive HF
Warm & dry Warm & wet
L C
Yes
No A B
Warm & dry Warm & wet
L C
Syok Kardiogenik
STEMI akut Killip 4
Yes
Inotropic drugs :
Dobutamine
Milrinon
Norepinephrine
IABP
European Heart Journal of Heart Failure,2005;
March. Vol 7:323-331
Management
Based of
Hemodynamic
Profile
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.
Eurheartj. 2016;
Recommendation For Oxygen Therapy
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.
ESC. 2016
Eurheartj. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure.
2016;
Eurheartj. 2016;
Pharmacological Agents:
Acute Treatment
Diuretic
Mechanism :
Diuretic
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart
failure. Eurheartj. 2016;
Pharmacological Agents:
Acute Treatment
Opiates
Mechanism :
Reduce anxiety
Relieve distress associated with dyspnoea
Venodilators characteristic
Reducing preload
Reducing sympathetic drive
Side effects :
Respiratory distress
Nausea
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eurheartj.
Pharmacological Agents:
Acute Treatment
Vasodilators
Mechanism : Reduce preload and afterload and
increase stroke volume
Most useful in patients with hypertension
Should be avoided in patients SBP < 90 mmHg.
Avoid excessive falls in blood pressure
hypotension is associated with higher mortality
Recommendation For
Vasodilator Drug
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
Pharmacological Agents:
Inotropes
Acute Treatment
Reserved for severe CO reduction (Cardiogenic shock).
May cause sinus tachycardia,ischaemia and arrhythmias.
Long-standing concern that they may increase mortality.
Vasopressors
peripheral arterial vasoconstrictor
action e.g NE
Raise BP and Redistribute CO to
the vital organs
adverse effects similar to
inotropes
Restricted to patients with
persistent hypoperfusion despite
adequate cardiac filling pressures.
Recommendation For Inotropic and
Vasopressor Drug
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
Pharmacological Agents:
Stabilized
ACEi/ARB
Should be started as soon as possible (esp rEF) BP and renal function
evaluation
up-titrated as far as possible before discharge, and a plan made to
complete dose up-titration after discharge
Aldosteron Reseptor Antagonis
Should be started as soon as possible (esp rEF) renal function and
Potassium evaluation
MRA dose for HF has minimal effect on BP start during admission
regardless of hypotension
up-titrated as far as possible before discharge, and a plan made to
complete dose up-titration after discharge
Pharmacological Agents:
Stabilized
Beta-blocker
Digoxin
rEF, control the Ventricular Responsee in AF if impossible to up-
titrate the beta-blocker.
Provide symptom benefit and reduce the risk of HF hospitalization in
patients with severe systolic HF
Non Pharmacological Therapy :
Fluid Restriction
Restrict sodium intake to <2 g/day and fluid intake to <1.5
2.0 L/day during the initial management of an acute
episode of HF
Non Pharmacological Therapy:
Ventilation
A. Non Invasive
B. Invasive
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
AHF with Cardiogenic Syock
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
AHF with Acute Lung Oedema
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
AHF with ACS
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
AHF with Atrial Fibrilation
ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
ESC. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic
heart failure. Eurheartj. 2016;
Case Illustration
Identitas
Nama : Ny LPH
Jenis kelamin : wanita
Usia : 66 thn
Pendidikan :-
Alamat : Sambas, Kalimantan Barat
No RM : 2016-41-12-83
Tanggal Masuk : 31-08-2016
Anamnesa
Dilakukan secara : Aloanamnesa
Keluhan Utama : Sesak Napas
Riwayat Penyakit Sekarang
Pasien mengalami sesak napas yang semakin memberat sejak 1
bulan yang lalu. Pasien mengalami sesak napas yang bertambah
dengan aktivitas. Pasien tidur dengan beberapa bantal. Ada
riwayat terbangun pada malam hari karena sesak. Keluhan
demam dan nyeri dada disangkal.
Pasien dirujuk dari RS GK dengan diagnosis MR acute ec ruptur
chordae papilaris ec MCI posterior + lung oedem refrakter. Tiga
minggu yang lalu pasien dirawat di bandung dengan keluhan
batuk-batuk.
Dua minggu yang lalu os dinyatakan mengalami infeksi paru-
paru dan dirawat di RS GK, mengalami perburukan dan
dilakukan intubasi lalu dirujuk ke RSJHK.
Riwayat Penyakit Dahulu
Riwayat DM (+)
Hipertensi (+)
Dislipidemi (+)
Riwayat Terapi Sebelumnya
Noradrenalin 0,09 mcg/Kg BB/ jam
Dobutamine 5 mcg/Kg BB/jam
Furosemide 20 mg/jam
Meropenem 3 x 1 gr
Cravit 1x 750 mg/hari
Gastrofer 2x1 iv
Ondansetron 2 x 8 mg iv
Vectrin 3x1
Atorvastatin 1x1
Sukralfat 3x10cc
Ramipril 3x2,5mg
Pemeriksaan Fisik
Kesadaran : Somnolen, terintubasi
Tanda vital :
TD : 95/65 dengan support
HR : 110x/menit
RR : 30x/menit, Sat O2 : 100% on intubasi
Cor : S1, S2 reguler, pansistolik murmur 2/6 di apex,
gallop tidak ada
Pulmo : vesikuler, ronkhi basah halus kedua lapang paru,
wheezing -/-
abdomen : supel , BU normal, Liver tak teraba membesar
Ekstrimitas : oedem -/-, akral hangat
EKG
EKG (cont)
EKG (cont)
Penunjang
Ro Thorax (RS GK) : Kardiomegali, oedem paru bilateral
terutama kanan
DPL (RS Graha) : Hb 11,4; L 15.200; Tr 319.000; Ur 52; Cr 0,9;
GDS 138 gr/dl
AGD : pH 7,26; pO2 163; pCO2 54; saO2 99%; BE -2,6
Elektrolit : Na 141; K 4,7; Cl 98
PCR TB (-)
Analisis Cairan Effusi : Cairan jernih , mengandung lekosit, sel
ganas (-)
Rontgen
2 September 2016
Echocardiography
Dilakukan tanggal 1 September 2016
Pemeriksaan on norepinephine 0.05 mcg/kgBB/min dan
dobutamin 5 mcg/kgBB/min
Hasil:
EDP = 67 / ESD = 56 / EF 39% / TAPSE 1,7
Hipoketik berat inferior, inferolateral
MR severe ec. Prolaps & flail PML
Ruptur kordae (+) peak E 2,0, PV sistolik Rev (+)
IVC = 22/16 ; LVOT VTI = 21 cm ; LVOT diameter = 1,8 ; SV
= 53,4 ; CO = 5,4 liter / menit ; SVR = 745 dyne
Kesan: Volum cukup, SV dan CO normal, SVR menurun
Diagnosa Kerja
Acute MR severe ec. MVP, rupture cordae