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2.1. Definition of Heart Failure Heart failure is a complex clinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood. The cardinal manifestations of HF are dyspnea and fatigue, which may limit exercise tolerance, and fluid retention, which may lead to pulmonary congestion and peripheral
edema.
A PREVALENT CONDITION
PREVALENCE OF HEART FAILURE (PER 1000 POPULATION)
Men 8 66 7.4
Women 8 79 7.7
A GROWING BURDEN
DEATHS FROM HF 1979-1997 (USA)
50000 40000
HF deaths
Source: Vital Statistics of the United States, National Center for Health Statistics
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NEURO-HORMONAL ACTIVATION
AS A SIGNIFICANT FACTOR CONTRIBUTING TO PROGRESSIVE SYSTOLIC DYSFUNCTION AND PROGRAMMED MYOCARDIAL CELL DEATH, ALSO CALLED APOPTOSIS
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NEURO-HORMONAL ACTIVATION
NOREPINEPHRINE CAUSED VASOCONSTRICTION, INCREASED HEART RATE AND MYOCYTE TOXICITY ANGIOTENSIN II CAUSED VASOCONSTRICTION, STIMULATES RELEASE OF ALDOSTERONE AND ACTIVATES THE SYMPATHETIC NERVOUS SYSTEM ALDOSTERONE CAUSED SODIUM AND WATER RETENTION
NEURO-HORMONE SECRETION IN RESPONSE TO HEART FAILURE ENDOTHELINE CAUSED VASOCONSTRICTION AND MYOCYTE TOXICITY
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INTERLEUKIN I (IL-1) AND IL-6 CAUSED MYOCYTE TOXICITY NEURO- HORMONE (ATRIAL NATRIURETIC PEPTIDE AND BRAIN NATRIURETIC PEPTIDE) CAUSED VASODILATATION, EXCRETION OF SODIUM AND ANTIPROLIFERATIVE EFFECT ON MYOCYTES
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ETHYOLOGY
The most common cause of heart failure is left ventricular (LV) systolic dysfunction (about 60% of patients). In this category, most cases are a result of end-stage coronary artery disease, either with a history of myocardial infarction or with a chronically underperfused, yet viable, myocardium. In many patients, both processes are present simultaneously . Other common causes of LV systolic dysfunction include idiopathic dilated cardiomyopathy, valvular heart disease, hypertensive heart disease, toxin-induced cardiomyopathies (alcohol), and congenital heart disease .
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1. 2. 3. 4.
CORONARY ARTERY DISEASE : AMI HYPERTENSIVE HEART DISEASE VALVULAR HEART DISEASE ex. AS,MS CARDIOMYOPATHY : Restrictive, Dilated Hyperthrophic 5. PERICARDIAL DISEASE 6. HIGH OUTPUT SYNDROME ex. ANEMIA, HYPERTHYROIDIS 7. AGE RELATED DIASTOLIC SYNDROME
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1. RENAL DYSFUNCTION 2. CHRONIC LUNG DISEASE 3. COGNITIVE DYSFUNCTION: DIETARY,MEDICATION ec 4. DEPRESSION, SOSIAL ISOLATION 5. URINARY INCONTINENCE 6. NUTRITIONAL DISORDER 7. POLYPHARMACY DRUG INTERACTION
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RIWAYAT KLINIK
PASCA INFARK MIOKARD ANGINA PEKTORIS HIPERTENSI KELAINAN KATUP/ DEMAM REMATIK PENYAKIT JANTUNG BAWAAN PALPITASI
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PHYSICAL EXAMINATION
SYSTOLIC HEART FAILURE DIASTOLIC HEART FAILURE
CLASIFIED BY AN EJECTION FRACTION LESS THAN 40 % , IS CHARACTERIZED BY A REDUCED CARDIAC OUTPUT SECONDARY TO DEPRESSED MYOCARDIAL CONTRACTILITY.
CLASSIFIED BY A NORMAL EJECTION FRACTION ( GREATER THAN OR EQUAL TO 50 %, IN THE PRESENCE OF PULMONARY CONGESTION AND OTHER HF SYMPTOMS ( FOR EX. . DYSPNEA D EFFORT,PND , FATIGUE, AND ORTHOPNEA) AND FOURTH HEART SOUND.
DIAGNOSIS
In general, a definitive diagnosis can be made when the rate of ventricular relaxation is slowed; this physiological abnormality is characteristically assocated with the finding of an elevated LV filling pressure in a patient with normal LV volumes and contractility
CLASSIFICATION OF HEART FAILURE Patients in Class IV heart failure are virtually unable to do any physical activity without discomfort. There may be significant signs of cardiac problems even while resting. Surgical options will be explored along with the same attention given to treatments in Classes I-III.
PHYSICAL SIGNS
There are a few physical signs that may indicate Heart Failure. Fluid retention, which causes weight gain and possible swelling of the feet, ankles, or even abdomen, is associated with the disease. Another physical sign is bulging of the neck veins. When the pulmonary veins arent functioning as they should, an insufficient supply of blood is making it to the heart, thus causing fluid to build up in the arteries and body tissues (edema).
SYMPTOMS OF CHF
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IF HISTORY AND PHYSICAL EXAMINATION CLEARLY INDICATE A NON CARDIAC CAUSE FOR THESE SYMPTOMS( EG. SEVERE PULMONARY DISEASE), THEN HEART FAILURE EVALUATION IS NOT NECESSARY. Continued
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SYMPTOMS OF CHF
YOUNG ADULT PATIENTS ELDERLY PATIENTS
1. DYSPNEA ON EXERTION 2. DYSPNEA AT REST 3. ORTHOPNEA 4. PAROXISMAL NOCTURNAL DYSPNEA (PND) 5. FATIGUE 6. ANKLE SWELLING
1. 2. 3. 4. 5. 6. 7. 8.
DYSPNEA ON EXERTION CONFUSION AGITATION DEPRESSION INSOMNIA WEAKNESS ANOREXIA OR NAUSEA COUGH
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PHYSICAL EXAMINATION
SYSTOLIC HEART FAILURE DIASTOLIC HEART FAILURE
CLASIFIED BY AN EJECTION FRACTION LESS THAN 40 % , IS CHARACTERIZED BY A REDUCED CARDIAC OUTPUT SECONDARY TO DEPRESSED MYOCARDIAL CONTRACTILITY.
CLASSIFIED BY A NORMAL EJECTION FRACTION ( GREATER THAN OR EQUAL TO 50 %, IN THE PRESENCE OF PULMONARY CONGESTION AND OTHER HF SYMPTOMS ( FOR EX. . DYSPNEA D EFFORT,PND , FATIGUE, AND ORTHOPNEA) AND FOURTH HEART SOUND.
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PEMERIKSAAN PENUNJANG
1. 2. 3. 4. 5. 6. 7. PEMERIKSAAN EKG FOTO RONGEN THORAKS HEMOGLOBIN FUNGSI TIROID FUNGSI GINJAL FUNGSI HATI PEMERIKSAAN EKOKARDIOGRAFI
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PENATALAKSANAAN
PENTING UNTUK MENGENALI SECARA DINI PASIEN INI KARENA PROGNOSANYA DAPAT MEMBAIK. TERAPI : BETA BLOCKER/ PENGHAMBAT BETA, ACE INHIBITOR/ PENGHAMBAT ACE, DIKOMBINASIKAN DENGAN DIURETIKA, DIGITALIS ATAU VASODILATOR
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PENATALAKSANAAN
PENTING UNTUK MENGENALI SECARA DINI PASIEN INI KARENA PROGNOSANYA DAPAT MEMBAIK. TERAPI : MENGATASI PENYAKIT YANG MENDASARI/ MENGIKUTINYA SEPERTI HIPERTENSI HARUS DIBERIKAN OBAT UTK. MENGURANGI TENSI DAN MENCEGAH HIPERTROFI VENTRIKEL KIRI. TANDA-2 KONGESTI /BENDUNGAN DIKURANGI DENGAN DIURETIKA.
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PENATALAKSANAAN
PENTING UNTUK MENGENALI SECARA DINI PASIEN INI KARENA PROGNOSANYA DAPAT MEMBAIK. TERAPI : MENGATASI PENYAKIT YANG MENDASARI. PEMBEDAHAN DAN PROSEDUR INTERVANSI SEPERTI VALVULOPLASTI /VALVULOTOMI MEMBERIKAN HASIL YANG BAIK. KELAINAN REGURGITASI KATUB YANG TIDAK DAPAT DIOPERASI, DAPAT DIBERIKAN DIURETIKA DAN VASODILATOR
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PENATALAKSANAAN
PENTING UNTUK MENGENALI SECARA DINI PASIEN INI KARENA PROGNOSANYA DAPAT MEMBAIK. TERAPI : MENGATASI PENYAKIT YANG MENDASARI. PEMBEDAHAN DAN PROSEDUR INTERVENSI SEPERTI KOREKSI/PENUTUPAN DEFECT MEMBERIKAN HASIL YANG BAIK. KELAINAN BAWAAN YANG TIDAK DAPAT DIOPERASI MIS. ASD +PH DENGA MPA 70 mm HG, DAPAT DIBERIKAN DIURETIKA DAN VASODILATOR
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PENATALAKSANAAN
PENTING UNTUK MENGENALI SECARA DINI PASIEN INI KARENA PROGNOSANYA DAPAT MEMBAIK. TERAPI : DISINI DIPERLUKAN PERBAIKAN NUTRISI, FAKTOR HORMONAL DAN METABOLIK YANG DAPAT MENYEMBUHKAN KELAINAN INI.
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1.
2. 3. 4. 5. 6.
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PEMERIKSAAN PENUNJANG
1. 2. 3. 4. 5. 6. 7. PEMERIKSAAN EKG FOTO RONGEN THORAKS HEMOGLOBIN FUNGSI TIROID FUNGSI GINJAL FUNGSI HATI PEMERIKSAAN EKOKARDIOGRAFI
TO IMPROVE SURVIVAL
ACE INHIBITORS BLOCKERS ORAL NITRATES PLUS HYDRALAZINE SPIRONOLACTONE
BLOCKERS
RISK REDUCTION 38%
HOSPITALIZATIONS)2 (MORTALITY AND
Davies et al. BMJ 2000;320:428-431 (meta analysis: 32 trials, n=7105) 2000;320:495-498 (meta analysis: 18 trials, n=3023)
BLOCKADE OF RAS
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RENIN INHIBITOR
CHYMA
ANGIOTENSIN I
BRADYKININ
PEPTIDES
ACE INHIBITOR
ANGIOTENSIN II
VALSARTAN
AT1 RECEPTOR BLOCKER
AT1
AT2
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AT2
VASODILATION ANTIPROLIFER ATION APOPTOSIS
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Patients with symptomatic HF of any cause, EF 40 %, in NYHA class II/III, clinically stable, already on treatment wite ACE inh., diuretic, and digitalis
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Blocker summary
1. At one time contraindicated in the treatment of heart failure 2. The increased activation of the adrenergic system induced by heart failure, provides the rationale for the use of Blockers in heart failure 3. While the effect of Blockers on exercise capacity, quality of life, and the neurohormonal profile are still controversial, the LV shape and function, and the need for hospitalisation are improve by Blockers in heart failure
Continued
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Blocker summary
4. On the basis of all available evidence, all patients with chronic, stable, mild to moderate, symptomatic HF (NYHA CLASS II/III), and with the depressed LV function should be treated with Blockers 5. The studies showed that Blockers significantly reduce total and sudden mortality in HF patients 6. Blockers tretment should be started in stable patients with a very low initial dosage and then uptitrated in the maximal tolerated
Continued
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Blocker summary
7. Despite the impressive results in term of morbidity and martality reduction, and the increasing availability of Blockers, these data showing only a minority of patients being treated At one time contraindicated in the treatment of heart failure
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DIURETICS
DIURETICS SHOULD BE USED FOR ALL PATIENTS WITH SYMPTOMS WHO HAVE EVIDENCE FOR FLUID RETENTION SHOUD NOT BE USED ALONE, EVEN IF THE SYMPTOMS OF HF ARE WELL CONTROLLED. ALTHOUGH THEY PRODUCED RAPID SYMPTOMATIC RELIEF, THEY CANNOT MAINTAIN CLINICAL STABILITY IN LONG- TERM, SO THEYFORE GENERALLY BE ADMINISTERED WITH ACE INH/ BLOCKERS
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ANTIARRHYTMIC DRUG
In addition to progressive pump dysfunction, 25 70 % of all deaths patients with HF, caused by ventricel arrhytmia Of the available antiarrhytmia, amiodarone is the only one which seem to be potentially beneficial in patients with HF, suppressing atrial and ventricular arrhytmia
NITRATES
The use of nitrates in HF is most commonly ,in patients who cannot tolerate ACE inhibitors due to hypotension or renal insufficiency .
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Ca. antagonists
Ca. Antagonists are not recommended for use in HFdue to their association with an increased risk of cardiovascular event
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CYTOKINES
CYTOKINES ARE BEING IMPLICATED FOR PATHOGENIC ROLE IN HF PROGRESSION Cytokines antagonist : IL-6 antagonist and TNF antagonist currently under investigation for HF treatment
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CONCLUSIONS
THE PHARMACOLOGICAL TREATMENT OF HF HAS BECOME COMBINED SYMPTOMATIC - PREVENTIVE MANAGEMENT STATEGY EARLY RECOGNATION AND PREVENTION THERAPIES COMBINED WITH LIFESTYLE MODIFICATION, ARE ESSENTIAL
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CONCLUSIONS
APPLY THE GUIDELINES TO EVERY PATIENTS AS INDIVIDUAL, ADJUSTING THE TREATMENT REGIMEN AS INDICATED BY A PATIENTS S CONDITION AND WHAT THE GROWING MEDICAL EVIDENCE BASE DEEMS APPROPRIATE THERE ARE MANY APPROACHS WERE DESCRIBED AS THE RECENT MANAGEMENT
THANK YOU
A PREVALENT CONDITION
Men 8 66 7.4
Women 8 79 7.7
A GROWING BURDEN
50000 40000
HF deaths
ital Statistics of the United States, National Center for Health Statistics
BLOCKERS
RISK REDUCTION 38%
HOSPITALIZATIONS)2 (MORTALITY AND
TO IMPROVE SURVIVAL
ACE INHIBITORS BLOCKERS ORAL NITRATES PLUS HYDRALAZINE SPIRONOLACTONE
Davies et al. BMJ 2000;320:428-431
AN ECONOMIC BURDEN
ANNUAL COST OF HF ESTIMATED TO BE $22.5 BILLION (USA)
Healthcare Drugs providers Indirect Costs 2.2 1.5 1.1 2.2 Home health/Other medical durables
15.5
Hospital/Nursing home