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Strategis penanganan gagal jantung akut dan kronis : - perbaiki gejala klinis dan prognosis Penanganan tergantung pada etiologi dan beratnya kondisi pasien, sehingga intervensi yang tepat dapat memperbaiki prognosis
Survival rates (%) compared with chronic heart failure At 1 year Breast cancer Prostate cancer Colon cancer Heart failure 88 75 56 67 At 2 years 80 64 48 41 At 3 years 72 55 42 24
Penanganan Gagal Jantung Akut (GJA) Pemeriksaan GK : ansietas, takikardi dan dispnu Syok kardiogenik : muka pucat, hipotensi (TDS < 90 mmHg) oliguria dan Cardiak Output (CO) rendah Gagal jantung berat dan syok kardiogenik bisa terjadi pada : Infark miokard luas, Aritmia kordis berkepanjangan (AF,VT), problem mekanis (ruptur m. papilaris akut, post infark VSD)
Gagal jantung yang berat : Kasus emergensi - perlu penanganan efektif - perlu pemeriksaan untuk mengetahui penyebab, memperbaiki status hemodinamik, mengatasi bendungan paru, memperbaiki oksigenasi jaringan - Pemeriksaan klinis dan radiologis severity dan prognosis - Klasifikasi Killip : menilai severity GJA dan GJK
Killip classification Class Class I Class II Class III Class IV Clinical features No signs of left ventricular dysfunction S3 gallop with or without mild to moderate pulmonary congestion Acute severe pulmonary oedema Shock syndrome Hospital mortality (%) 6 30 40 80 - 90
Pengobatan
posisi pasien duduk tegak lurus, oksigen konsentrasi tinggi (face mask) observasi ketat monitor di ICCU perlu kateterisasi urine balance cairan periksa AGDA (oksigenasi dan keseimbangan asam basa) - Base Excess (BE) panduan untuk perfusi jaringan - Bila BE lebih negatif pada GJA asidosis laktat akibat metabolisme anaerob (prognostik buruk) Infus Bikarbonat (kasus refrakter)
Loop diuretik IV : frusemide (furosemide) venodilatasi sementara diberikan pada pasien udem pulmonum meningkatkan produksi vasodilator prostaglandin di renal (perbaikan simptomatis dan diuresis) NSAID dihindari (inhibitor prostaglandin) Opiat atau opioid parenteral (morphine atau diamorphine) menghilangkan ansietas, nyeri dan disstres menurunkan kebutuhan oksigen miokardial menimbulkan venodilatasi menurunkan preload, tekanan pengisian jantung dan kongesti paru
Nitrat (sublingual, buccal dan IV) menurunkan tekanan preload dan tekanan pengisian jantung berguna pada angina dan gagal jantung Sodium nitroprusside : vasodilator yang bekerja langsung dan kuat (kasus GJA refrakter)
Acute heart failure ; basic measures and initial drug treatment
Basic measures Sit patient upright High dose oxygen Initial drug treatment
Intravenous loop diuretics Intravenous opiates/opioids (morphine/diamorphine)
Corrects hypoxia
Acute heart failure; second line drug treatment and advanced management
Second line drug treatment Inotropes ; agonists (dobutamine) Dopamine (low dose)
Inotropes ; phosphodiesterase Inhibitors (enoximone)
Increase myocardial contractility Increases renal perfusion, sodium Excretion, and urine flow
Increase myocardial contractility and venodilatation Weak inotropic effect, diuretic effect, Bronchodilating effect Reduces myocardial oxygen demand; Improves alveolar ventilation
Intravenous aminophylline
Advanced management
Assisted ventilation Circulatory assist devices
Intravenous inotropes and circulatory assist devices Short term support with intravenous inotropes or circulatory assist devices, or with both, may temporarily improve haemodynamic status and peripheral perfusion Such support can act as a bridge to corrective valve surgery or cardiac transplantation in acute and chronic heart failure
Penanganan Awal
Pendekatan non farmakologis dan perubahan gaya hidup Loop diuretik (bila overload cairan), selain restriksi garam dan mencegah retensi cairan ACE inhibitor (pada stadium awal bila tidak ada kontraindikasi) AIIRA bila tak tahan dengan ACE inhibitor bloker (carvedilol, bisoprolol, metoprolol) diberikan pada pasien stabil dengan dosis rendah dan dinaikkan secara titrasi dibawah pengawasan spesialist Digoxin oral, pada pasien disfungsi sistolik ventrikel kiri yang tidak ada perbaikan dengan diuretik dan ACE inhibitor optimal Warfarin diberikan pada pasien atrial fibrilasi
CHF Berat
Perlu perawatan RS, walau telah diberikan perawatan konvensional Restriksi cairan (intake cairan: dikurangi sampai 1-1,5 liter/24 jam) Diet rendah garam Bed rest sampai terjadi perbaikan klinis, tetapi dapat meningkatkan resiko tromboemboli vena profilaksis heparin subcutaneus Antikoagulan dianjurkan pada Atrial Fibrilasi dan pada disfungsi sistolik ventrikel kiri dengan disertai dilatasi ventrikel Loop diuretik IV untuk mengatasi udema usus sehingga menurunkan absorbsi obat bisa diberikan bersama-sama thiazide oral atau thiazide-like diuretik (metolazone) Spironolakton dosis rendah (25 mg) meningkatkan morbiditas dan mortalitas bila dikombinasikan dengan obat konvensional Kadar Potassium harus dimonitor bila memakai spironolakton
Management of chronic heart failure General advice Counseling about symptoms and compliance Social activity and employment Vaccination (influenza, pneumococcal) Contraception General measures Diet (for example, reduce salt and fluid intake) Stop smoking Reduce alcohol intake Take exercise Treatment options pharmacological Diuretics (loop and thiazide) Angiotensin converting enzyme inhibitors Blockers Digoxin Spironolactone Vasodilators (hydralazine / nitrates) Anticoagulation Antiarrhythmic agents Positive inotropic agents Treatment options devices and surgery Revascularisation ( PTCA and CABG ) Valve replacement ( or repair ) Pacemaker or implantable cardiodefibrillator Ventricular assist devices Heart transplantation
Symptomatic
Add loop diuretic (eg frusemide)
Asymptomatic
ACE inhibitor ACE inhibitor Consider blocker* in patients with chronic, stable condition
Persisting clinical features of heart failure Options Optimise dose of loop diuretic Low dose spironolactone (25 mg once a day) Digoxin Combine loop and thiazide diuretics Oral nitrates / hydralazine
Atrial fibrillation Angina Options Digoxin Options blocker blocker (if not already given) (if not already given) Oral nitrates Warfarin Calcium antagonist (eg amlodipin)
Consider specialist referral in patient with atrial fibrillation (electrical cardioversion or Other antiarhythmia agents (eg amiodarone may be indicated),angina (coronary Angiography and revascularisation nay be indicated), or persistent or severe symptoms
In the United Kingdom carvedilol is used for mild to moderate symptoms and bisoprolol for moderate to severe congestive heart failure
* Initial low dose (eg carvedilol, bisoprolol, metoprolol) with cautious titration under expert supervision
Supervised exercise programmes are of proved benefit, and regular exercise should be encouraged in patients with chronic stable heart failure Weighing the patient daily is valuable in monitoring the response to treatment
Education, counselling, and support A role is emerging for heart failure liaison nurses in educting and supporting patients and their families, promoting long term compliance, and supervising treatment changes in the community Depression is common, underdiagnosed, and often undertreated; counselling is therefore importantfor patients and families, and the newer antidepressants ( particularly the selective serotonin reuptake inhibitors ) seem to be well tolerated and are usefull in selected patients
Tindakan khusus
Pompa Balon Intra-aorta dan Peralatan mekanis
Intra-aortic ballon couterpulsation dan alat bantu ventrikel kiri digunakan sebelum dilakukan operasi koreksi katup jantung, transplantasi jantung atau CABG Alat mekanis diindikasikan bila : a). Terdapat kemungkinan perbaikan spontan (kardiomiopati peripartum b). Sebelum dilakukan operasi jantung (ruptur m. papilaris mitral, post infark VSD ) c). Transplantasi jantung
Indications and contraindications to cardiac transplantasion in adult Indications End stage heart failure for example, ischaemic heart disease and dilated cardiomyopathy Rarely, restrictive cardiomyopathy and peripartum cardiomyopathy Congenital heart disease (often combined heart-lung transplantation required) Absolute contraindications Recent malignancy (other than basal cell and squamous cell carcinoma of the skin) Active infections (including HIV, Hepatitis B, Hepatitis C with liver disease) Systemic disease which is likely to affect life expectancy Significant pulmonary vascular resistance Relative contraindications Recent pulmonary embolism Symptomatic peripheral vascular disease Obesity Severe renal impairment Psychosocial problems for example, lack of social support, poor compliance, psychiatric illness Age (over 60 65 years)
Transplantasi jantung
Transplantasi jantung dapat meningkatkan survival rate dan kualitas hidup Kebutuhan akan transplantasi organ telah meningkat, tetapi jumlah operasi transplantasi tetap stabil karena terbatasnya organ Dengan adanya transplantasi jantung, mortalitas < 10%, survival rate 1,5,10 tahun : 92%, 75%, 60% lebih baik dibandingkan dengan obat-obatan (angka mortalitas 1 tahun 30% - 50% pada gagal jantung
Survival jangka panjang transplantasi manusia dipengaruhi oleh kecepatan terjadinya aterosklerosis pada graft, yang terjadi diawal tiga bulan setelah operasi Obat anti- rejeksi yang sering dipakai : cyclosporin dan obat imunosupresant lainnya Dari Eurotransplant database (1990-5) : 25% pasien meninggal saat menunggu donor, hanya 60% yang menerima transplantasi dalam jangka 2 tahun (rata-rata 12 bulan)