DEFINISI

Keadaan patofisiologi dimana jantung tidak mampu memenuhi kebutuhan jaringan dengan kecepatan yang sesuai dengan kebutuhan metabolisme jaringan atau hanya dapat dengan meningkatkan tekanan pengisian(Braunwald) Sindroma klinik akibat gangguan struktur atau fungsional jantung yang berakibat terganggunya kemampuan ventrikel untuk mengisi dan memompa darah(ACC/AHA)
Braunwald E. Heart Failure.In:Braunwald E, Fauci AS, Kasper DL(editor),Harrison s Principle of Internal Medicine. 15th edition. McGrawHill:NewYork ACC/AHA 2005 Guideline update for the diagnosis and management of chronic heart failure in the adult. Circulation 2005;112:1825-52

DEFINISI
EUROPEAN SOCIETY OF CARDIOLOGY I. Symptoms of heart failure(at rest and during exercise) AND II. Objective evidence (preferably by echocardiography) of cardiac dysfunction (systolic and/or diastolic)(at rest) and (in cases where the diagnosis is in doubt) AND III.Response to treatment directed towards heart failure

Criteria I and II should be fulfilled in all cases

Swedberg K, et al. Guideline for the diagnosis and tratment of chronic heart failure: executive summary(update 2005). European Heart Journal 2005;26: 1115-1140

KLASIFIKASI GAGAL JANTUNG

New York Heart Association
Class I

No limitation:ordinary physical exercise does not cause undue fatique, dyspnoe,or palpitation Slight limitation of physical activity: comfortable at rest but ordinary activity results in fatique, palpitation, or dypne Marked limitation of physical activity: comfortable at rest but less than ordinary activity results in symptom
Unable to carry out any physical activity without discomfort: symptoms of heart failure are present even at rest with increased discomfort with any physical activity

Class II

Class III

Class IV

STAGING GAGAL JANTUNG

American College of Cardiology/American Heart Association No structural heart disease and no symptoms but risk factors:CAD, hypertension, diabetes, cardiotoxin, familial cardiomiopathy Abnormal LV systolic function, MI, valvular heart disease but no HF symptoms Structural heart disease and HF symptoms
Stage A

Stage B

Stage C

Stage D

Refractory HF symptoms to maximal medical management

ETIOLOGI
Mechanical abnormalities Pressure overload Aortic stenosis Arterial hpertension Pulmonary hypertension Coarctation of the aorta Pulmonary stenosis Volume overload Valvular regurgitation Anemia Thyrotoxicosis Shunts Mitral stenosis Pericardial constriction or tamponade Ventricular dilatation/aneurysm Restriction of ventricular filling Mitral stenosis Constrictive pericarditis Left ventricular hypertrophy Endomyocardial fibrosis Myocardal disease Primary Hypertrophic cardiomyopathy Restrictive cardiomyopathy Idiopathic dilated cardiomyopathy Secondary Coronary artery disease Myocardial infarction Chronic myocardial ischemia Silent ischemia Metabolic Alcohol cardiomyopathy Nutritional Thyroid disorder Hypocalcemia Pheocromocytoma Drugs Disopyramide/flecanaide Amphetamine Anthracycline(doxorubicin) Heroin/cocaine Metals Iron overload Primary(hemochromatosis) Secondary(chronic transfusion) Lead poisoning Cobalt poisoning
Acute rheumatic fever Infectious Bacterial,viral,parasitic,mycotic Ricketssial

Connective tissue diseases Rheumatoid arthritis Systemic lupus erythematosus Polyarteritis nodusa Scleroderma Dermatomyositis Neurologic disease Myotonic dystrophy Erbs limb-girdle muscular dystrophy Roussy-Levy polyneuropathy Friedrich ataxia Inherited disease Glycogenstorage disease Mucopolysaccharidoses Systemic carnitine deficiency Hypertaurinuria Farbys disease Osteogenesis imperfecta Other diseases Amyloid disease Endomyocardial biopsy Acute and chronic leukemia Uremic cardiomyopathy Henoch-Schonlein purpura Wegeners granulomatosis Irradiation to heart

DIAGNOSIS GAGAL JANTUNG

Identifikasi pasien gagal jantungtanda dan gejala klinis Tentukan kapasitas fungsionalklasifikasi NYHA Tentukan kelainan struktural dan fungsional ekokardiografi 2D Identifikasi kausa dan faktor pencetusanamnesis dan pemeriksaan fisik - Penyakit jantung koroner & iskemia miokard - Aritmia - Komorbid yang mempengaruhi terapi - Barier terhadap kepatuhan atau compliance

GEJALA KLINIS GAGAL JANTUNG

Gejala spesifik - Dyspnea deffortdyspnea at rest - Paroxysmal nocturnal dyspnea - Orthopnea - Fatigue & weakness Gejala tidak spesifik: - Angina,palpitasi - Sinkop,presinkop,confusion,delirium - Nausea,vomitus, abdominal discomfort - Wheezing, batuk(frothy sputum) - Nocturia,oliguria

Clinical manifestation (1)

Think about heart failure FACES F atigability A ctivities limited C hest (pulmonary) congestion

E dema (swelling) of ankles

S hortness of breath
(Heart Failure Society of America, 2000)

Ventricular Remodeling in CHF

TANDA KLINIS GAGAL JANTUNG

Vital sign: - Takikardia, takipnea, nadi irreguler(aritmia) - Pucat, dingin, sianosis(kecuali pada high-output failure) Tanda overload cairan: - Distensi vena jugularis(Sp.95%) - S3 gallop(Sp.95%); S4 gallop(Sp.50%) - Rales,wheezing,efusi pleura - Hepatojugular reflux - Hepatomegali,ascites,pitting edema tungkai,regio sakral, anasarka - Berat badan bertambahukur BB (BMI) Tanda kardiomegali - Laterally displaced or prominent apical impulse - Murmur(sekunder akibat regurgitasi mitral atau trikuspid) Cardiac cachexia

Framingham criteria for Congestive Heart Failure

Major Criteria Paroxysmal nocturnal dyspnea Neck-vein distension Rales Acute pulmonary edema S3 gallop Increased venous pressure > 16 cm H2O Circulation time > 25 sec Hepatojugular reflux Minor Criteria Ankle edema Night cough Dyspnea on exertion Hepatomegaly Pleural effusion Vital capacity increased 1/3 from maximun Tachycardia ( rate > 120/min)

Major or Minor Criteria Weight loss > 4.5 kg in 5 days in response to treatment Definite : - 2 major - 1 major + 2 minor

PEMERIKSAAN LABORATORIUM
Darah lengkap Elektrolit serum BUN,kreatinin Albumin serum Glukosa Tes fungsi hati Urinalisis Profil lipid(LDL,HDL,triglyceride) Hormon tiroid Enzim jantung Brain-type natriuretic peptide(BNP)

PEMERIKSAAN PENUNJANG
EKG - Nilai irama jantung dan gangguan konduksi - Hipertrofi ventrikel kiri - Durasi QRS - Iskemia atau infark miokard Foto thoraks PA&lateral - Kardiomegali(CTR0,5) - Edema paru - Penyakit paru lainnya Ekokardiografi 2D dengan Doppler - Ukuran, ketebalan dinding ventrikel kiri - Fraksi ejeksi ventrikel kiri(gagal jantung jika<40%) - Kelainan struktural-katup, perikardium, ventrikel kanan

FOTO THORAKS

Kerley B line

Cephalization

Background on Remodelling
Acute infarction (hours) Infarct expansion (hours to days)

Global remodelling (days to months)

Improvement of LV remodelling has been associated with improvement in mortality and morbidity outcomes in CHF

PEMERIKSAAN PENUNJANG
Exercise test Endomyocardial biopsy Radionuclide angiography Cardiac MRI Stress echocardiography Pulmonary function test Coronary angiography Pulmonary capillary wedge pressure(PCWP)

TATALAKSANA
Tujuan pengobatan gagal jantung kronik: Pencegahan Kontrol penyakit yang dapat menimbulkan disfungsi dan gagal jantung Pencegahan progresifitas dari disfungsi jantung menjadi gagal jantung Morbiditas Pemeliharaan atau perbaikan kualitas hidup Mencegah perawatan rumah sakit berulang Mortalitas Meningkatkan survival

TATALAKSANA
Terapi gagal jantung kronik meliputi: - Terapi non farmakologi - Terapi farmakologi - Nonoperatif(devices) - Pembedahan

TATALAKSANA FARMAKOLOGIS
Jessup M,Brozena S. Heart Failure. N Engl J Med 2003;348:2007-18

Chronic Congestive Heart Failure Evolution of Clinical Stages

NORMAL
No symptoms Normal exercise Normal LV fx

Asymptomatic LV Dysfunction No symptoms Compensated Normal exercise CHF Abnormal LV fx No symptoms Decompensated Exercise Abnormal LV fx CHF Symptoms Refractory Exercise CHF Abnormal LV fx

Symptoms not controlled with treatment

PROGNOSIS
Tergantung kepada usia, jenis kelamin, dan keparahan penyakit, etiologi dan faktor pencetus, serta respon terhadap terapi Pada studi Framingham(sebelum ACEI) Semua kelas NYHA8-year survival rate 30%, Kelas III & IV1-year mortality rate sebesar 34% Kelas IV1-year mortality rate 60%

GAGAL JANTUNG AKUT

DEFINISI
Acute heart failure is defined as the rapid onset of symptoms and signs secondary to abnormal cardiac function(ESC,2005) Bisa terjadi dengan atau tanpa penyakit jantung sebelumnya Disfungsi jantung bisa disebabkan karena disfungsi sistolik atau diastolik, gangguan irama atau preload-afterload mismatch Gagal jantung akut merupakan keadaan yang mengancam jiwa dan membutuhkan penangan yang segera

ETIOLOGI DAN FAKTOR PENCETUS

Dekompensasi gagal jantung kronik Sindrom koroner akut Krisis hipertensi Aritmia akut(VT,VF,AF,SVT) Regurgitasi katup/endokarditis/ruptur chordae tendinae, perburukan regurgitasi katup sebelumnya Stenosis aorta berat Miokarditis akut berat Tamponade kordis Diseksi aorta Kardiomiopati post-partum

ETIOLOGI DAN FAKTOR PENCETUS

Faktor pencetus non-kardiovaskuler - Rendahnya komplians dengan pengobatan - Overload cairan - Infeksi, khususnya pneumonia atau septikemia - Cidera otak berat - Post pembedahan mayor - Penurunan fungsi ginjal - Asma - Drug/alcohol abuse - Feokromositoma High output syndrome - Septikemia - Tiroktosikosis - Anemia

KLASIFIKASI

Dekompensasi akut gagal jantung kronik Edema paru kardiogenik akut Syok kardiogenik

DIET Approach to the Patient With Heart Failure

Diagnose
Etiology Severity (LV dysfunction)

Educate
Diet Exercise Lifestyle CV Risk

Initiate
Diuretic/ACE inhibitor -blocker Spirololactone Digoxin

Titrate
Optimize ACE inhibitor Optimize -blocker