Kenali Ceagh dan Obati Gagal Jantung M Saifur

Kenali, Ceagh dan Obati Gagal Jantung ! M. Saifur Rohman, MD, Ph. D Cardiologist Medical Faculty, Brawijaya University MSR, May 4 2010

Definition of HF n n A syndrome associated with inadequate performance of the heart. Leading to neurohormonal and circulatory abnormalities Adam KF et al. HFSA 2006 comprehensive heart failure guideline J Card Fail 2006; 12: e 1 -e 122

Epidemiology n n n Heart failure is a major and growing cause of cardiovascular morbidity and mortality throughout the world Approximately 5 million patients in USA have HF, and over 550 000 patients are diagnosed with HF for the first time each year. HF is the primary reason for 12 to 15 million office visits and 6. 5 million hospital days each year. ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008

Causes of HF • CAD • Hypertension • Valve disease (RHD, endocarditis) • Arrhythmias • Cardiomyopathy • Congenital heart disease • Pericardial Effusion

Systolic vs. Diastolic HF n n Heart failure is a major and growing cause of cardiovascular morbidity and mortality throughout the world Previously, it had often been assumed that most heart failure patients have underlying systolic dysfunction, which is responsible for their clinical presentation It has become increasingly apparent over the last decade that many heart failure patients have a normal or nearly normal ejection fraction described as heart failure with preserved systolic function or preserved ejection fraction HF-PEF affects primarily older patients, especially women; hypertension is the primary underlying condition, with CAD and prior MI being relatively infrequent Hogg K, Swedberg K, Mc. Murray J. J Am Coll Cardiol 2004; 43: 317 -327.

Systolic vs. Diastolic HF n 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 Diastolic Heart Failure/ HF-PEF Systolic Heart Failure ACC-AHA guidelines 2001

Pathological/Echocardiographic Differences in LV Thickness with Different Forms of HF Systolic heart failure Normal Heart failure with preserved systolic function Aurigemma GP et al. Circulation. 2006; 113: 296 -304.

Systolic HF vs HF-PEF: Signs and Symptoms Parameters Systolic HF-PSF History • Coronary artery disease • Hypertension • Diabetes • Valvular heart disease • Paroxysmal dyspnea +++ ++ + ++ ++ — +++ Physical Examination • Cardiomegaly • Soft heart sounds • S 3 gallop • S 4 gallop • Hypertension • Mitral regurgitation • Rales • Edema • Jugular venous distention ++++ +++ + ++ + + ++ ++ + + +++ Chest Roentgenogram (X-ray) • Cardiomegaly • Pulmonary congestion Givertz MM et al. In: Braunwald E, Zipes DP, Libby P, eds. Heart Disease, A Textbook of Cardiovascular Medicine. 7 th edition.

CHF vs. AHF n n n Current management of acute coronary syndrome has resulted in an improved survival after acute myocardial infarction. This fact has created a rapid growth in the number of patients currently living with chronic heart failure. Decompensation of preexisting chronic heart failure may cause acute heart failure (AHF). Eur Heart J 2005; 26: 384 -416

Definition of Acute Heart Failure • AHF is defined as the rapid onset of symptoms and signs, secondary to abnormal cardiac function • Cardiac dysfunction can be related to systolic or diastolic, to abnormalities in cardiac rhythm or to preload and afterload mismatch • It is often life threatening and requires urgent treatment ESC guideline for Acute Heart Failure, 2005

Cause of Acute Heart Failure n n Acute coronary syndrome, hypertensive crisis and other cardiac or non cardiac also precipitate an AHF. CAD contributes to 60 -70 % in elderly Cardiomyopathy, CHD, arrhythmia, myocarditis and valve diseases found in young AHF therefore has significantly become the single most costly medical syndrome in emergency. Eur Heart J 2005; 26: 384 -416

Cause of Acute Heart Failure Ischemic heart Disease Acute Coronary Syndromes Mechanical complication of acute MI RV infarction Valvular Valve stenosis Valve regurgitation Endocarditis Aortic disection Myopathies Postpartum cardiomyopathy Acute myocarditis Hypertension/arrhythmia Hypertension Arrhythmia Circulatory failure Septicemia Thyrotoxicosis Shunts Tamponade Pulmonary embolism Decompensation of preexisting CHF Lack of adherence Volume overload Infection; pneumonia Cerebrovascular insult Surgery Renal dysfunction Asthma, COPD Drug abuse Alcohol abuse ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008

Classification of AHF • Patient with AHF present with six distinct clinical conditions : Worsening decompensated of chronic HF Pulmonary edema Cardiogenic shock Hypertensive HF Isolated right HF ACS and HF ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008

Mortality of AHF n n n In Hospital mortality ( 60 days) : 9. 6% Rehospitalization and mortality : 32, 5% 1 year mortality : 30%. Fonarow GC. Rev Cardiovasc Med. 2001; 2(suppl 2): S 7–S 12.

Diagnosis of Heart Failure n n n Symptoms typical of HF Sign typical of HF Objective evidence of a structural or functional abnormality of the heart at rest ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008

Framingham Heart Failure Study Criteria Major n Acute pulmonary edema n PND or orthopnea n Crackles n S 3 gallop n HJR/Increased JVP n Cardiomegaly n Wt loss >4. 5 kg 5 d into Rx Minor n Night cough n Tachycardia >120 n Pleural effusion n Hepatomegaly n Ankle edema n Vital capacity decrease >1/3 from max *Two major or one major and two minor*

NYHA Functional Heart Class NYHA I: no symptoms on ordinary activity NYHA II: symptoms on ordinary exertion NYHA III: symptoms on less-than ordinary exertion NYHA IV: symptoms at rest

At Risk for CHF (ACC/AHA) Stage A Stage B At high risk of HF but without structural heart disease or HF symptoms: Structural Heart Disease but without signs or symptoms of HF: Pts. with HTN, CHD, diabetes, obesity, metabolic syndrome OR Pts. using cardiotoxins or family hx. cardiomyopathy Pts. with previous MI, LV remodeling including LVH, and low LVEF OR asymptomatic valvular disease

Heart Failure (ACC/AHA) Stage C Stage D Structural heart disease with prior or current HF: Refractory HF requiring specialized intervention: Pts. with known structural heart disease AND SOB, fatigue, reduced exercise tolerance Pts. with marked symptoms at rest despite maximal medical therapy Recurrent hospitalization Unsafe hospital discharge

Common Clinical Manifestation of HF ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008

Common ECG abnormalities in HF ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008

Common X-ray abnormalities in HF ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008

Common lab. abnormalities in HF ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008

Common echo. abnormalities in HF ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008

Diagnosis of HF Clinical examination, ECG, Xray, Echocardiography Natriuretic peptides BNP<100 pg/ml NT-pro. BN P<400 pg/m. L BNP 100 -400 pg/ml NT-pro. BNP 400 -2000 pg/ml BNP>400 pg/ml NT-pro. BNP>2000 pg/ml Uncertain diagnosis Chronic HF unlikely Chronic HF likely ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008

Assessment of Haemodynamic Profile Low perfusion at rest Congestion at rest No No Yes A B Warm & dry Warm & wet Cold & dry Cold & Wet Yes L Sign of congestion: Orthopnea, elevated JVP, edema, pulsatile hepatomegaly, ascites, rales, louder S 3, P 2 radiation left ward, abdomino-jugular reflex, valsava square wave C Sign of low perfusion: Narrow pulse pressure, cool extremities, sleepy, suspect from ACEI hypotension, low Na, renal worsening European Heart Journal of Heart Failure, 2005; 7: 323 -331

Treatment HF n n n Bed rest Fluid management Drug Device Stem cell

ERAS OF HEART FAILURE MANAGEMENT Non-pharmacological • Bed rest • Gene therapies • Digitalis • Inactivity • Fluid restriction • (Digitalis, diuretics) pre -1980’s Cellular/genetic Pharmacological 1980’s • Diuretics • Cell implantation/ regeneration • Neurohormonal interventions • Xenotransplantation 1990’s 2000’s 2020’s ⇒ Pharmacological Device • Digitalis • CRT • Diuretics • ICDs • Vasodilators • LVADs • Inotropes • Others? Heart Failure Updates, 2003

THE DONKEY ANALOGY Ventricular dysfunction limits a patient's ability to perform the routine activities of daily living… HEART FAILURE

TREATMENT OPTION FOR HF INOTROPIC Like the carrot placed in front of the donkey

ACEI AND DIURETICS Reduce the number of sacks on the wagon

ß-BLOKERS Limit the donkey’s speed, thus saving energy

Patient Treatment Selection Dry Warm Wet A Diuretic Vasodilator B Inotropic drugs : Dobutamine Milrinone Levosimendan Cold L C Fonarow GC. Rev Cardiovasc Med. 2001; 2(suppl 2): S 7–S 12.

Treatment Algorithm in AHF Acute Heart Failure Immediate symtomatic treatment Patient distress or in pain Yes Analgesia, sedation Pulmonary congestion Yes Medical therapy Diuretic/vasodilator Arterial Oxygen saturation < 95% Yes Increase Fi. O 2, consider CPAP, NIV Mechanical ventilation Normal heart rate and rhythm No Pacing, antiarrhythmias, electroversion ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008

Treatment Algorithm in AHF ESC Guideline for Acute Heart Failure, 2005

Treatment Algorithm in AHF ESC Guideline for Acute Heart Failure, 2005

AHF with Systolic Dysfunction Oxygen/CPAP Furosemide + vasodilator Clinical evaluation (leading to mechanistic therapy) SBP > 100 mm. Hg SBP 85 -100 mm. Hg SBP <85 mm. Hg Vasodilator (NTG, nitroprusside, BNP) Vasodilator and/or Inotropic (dobutamin PDEI or Levosimendan) Volume loading ? Inotrope and/or Dopamin > 5 mcg/kg/mnt And/or norepinephrine Good response Oral therapy Furosemide, ACE-I No respon : Reconsider mechanistic therapy Inotropic agent Eur Heart J 2005; 26: 384 -416

Treatment of HF ESC Guideline for Diagnosis and Treatment Acute and Chronic Heart Failure , 2008

HF Prevention n n Early diagnosis and prompt treatment of MI = ACS treatment Treat Hypertension Treat and prevent DM to prevent Cardiomyopathy DM Early diagnosis of Myocarditis to prevent cardiomyoptahy

From MI to HF n n Early diagnosis and vascularization prevent HF Delay and inadequate treatment iireversible cardiomyocyte loss

Myocardial infarction leads to heart failure n n n Obstruction of coronary arteries leads to myocardial infarction (heart attack) with the associated death of cardiomyocytes Regenerative capacity ? Not adequately compensate Overloads the surviving myocardium and eventually leads to heart failure Segers VF, Lee RT. Nature 2008; 451: 937 -942.

Terminal differentiation of cardiomyocytes n n n Cardiac myocytes rapidly proliferate during fetal life but exit the cell cycle soon after birth in mammals 1 The vast majority of adult cardiac myocytes the predominant form of growth postnatally is an increase in cell size (hypertrophy)2 This limits the ability to restore function after any significant injury 2 1. Ahuja P, et al. Physiol Rev 2007; 87: 521– 544. 2. Segers VF, Lee RT. Nature 2008; 451: 937 -942.

Problem with Infarcted Heart n n Current medical therapies of heart failure only delay progression of the disease The only standard therapy for cardiomyocyte loss is cardiac transplantation New discoveries on the regenerative potential of stem cells have transformed experimental research and led to an explosion in clinical investigation Results ? Segers VF, Lee RT. Nature 2008; 451: 937 -942.

HF Prevention n n Treat Hypertension Early diagnosis and prompt treatment of MI Treat and prevent DM to prevent Cardiomyopathy DM Early diagnosis of Myocarditis to prevent cardiomyoptahy

The Cardiovascular Continuum Coronary thrombosis Myocardial infarction Myocardial ischaemia X Prevention II Sudden Death Arrhythmia & loss of muscle Remodelling Ventricular dilatation CAD Atherosclerosis LVH X Prevention I Risk factors Hypertension, smoking, cholesterol, diabetes Dzau V. Braunwald E, Am Heart J. 1991 Congestive heart failure Death

Classification of Blood Pressure ESC-ESH 2007 Optimal : <120 and < 80 Normal : 120 -129 and/or 80 - 84 High Normal : 130 -139 and/or 85 -89 Grade 1 : 140 -159 and/or 90 -99 Grade 2 : 160 -179 and/or 100 -109 Grade 3 : > 180 and/or > 110 JNC VII committee, JAMA 2003: 289; 2560 -2572 JNC-VII Normal Pre-hypertension Stage 1 Stage 2 H Y PE R T E N S IO N

Epidemiology of Hypertension n n 90% lifetime risk of developing hypertension in people normotensive at age 55 People with lower educational and income levels tend to higher levels of blood pressure American Heart Association Heart Disease and Stroke statistic 2006 Update, Texas, AHA 2006

Prevalence of Hypertension Prevalence of hypertension in different regions of the world: Actual figures for 2000 - predicted for 2025 Rate of hypertension % 50 Men Women 40 2000 30 20 10 116. 2 123. 3 40. 8 52. 5 60. 4 57. 8 60. 0 54. 3 35. 9 37. 9 98. 5 83. 1 38. 4 33. 0 38. 2 41. 6 0 ± 2 x 50 40 number of people with HT (millions) 2025 30 20 10 147. 9 161. 8 44. 0 59. 7 107. 3 106. 2 102. 1 98. 5 72. 2 80. 4 151. 7 147. 5 67. 3 62. 1 73. 6 77. 1 O A t Is sia her la nd & s Su b -S ah a A ran fr ic a hi na C A m C er ar ic ib a be & an M id dl e Ea s C re ter sc n en t tin th e a di In La Ec Es ta bl is on M hed om ark Fo ie et s rm er S Ec oc on ial om ist ie s 0 number of people with HT (millions) Kearney et al Lancet 2005

Hypertension is Not Adequately Treated Off all the USA people with high blood pressure: n n n 11% are not on treatment regimen 25% are not on adequate treatment 34% are on adequate treatment American Heart Association Heart Disease and Stroke statistic 2006 Update, Texas, AHA 2006

Hypertension Prevalence and Treatment Prevalence of Hypertension Patients on Therapy 55 50 100 90 45 80 40 % US Canada Italy Sweden England Spain Finland Germany 35 % 30 25 70 60 50 40 20 15 30 20 10 10 5 0 0 Country Wolf-Maier K et al. JAMA. 2003; 289: 2363 -2369. Country

Controlled Hypertension < 140/90 mm. Hg USA 27 England 6 Canada 16 < 160/95 mm. Hg Finland Spain 20. 5 20 France Germany 24 22. 5 Scotland 17. 5 Australia 19 India 9 > 65 years USA: JNC VI. Arch Intern Med 1997 Marques-Vidal P et al. J Hum Hypertens 1997 Canada: Joffres et al. Am J Hypertens 1997 Adapted from G. Mancia / L. Ruilope England: Colhoun et al. J Hypertens 1998 France: Chamontin et al. Am J Hypertens 1998

Uncontrolled BP in Outpatient Clinic Three hundred third teen patients were randomly chosen among patients with or without known hypertension visited to Harapan Kita out patient HTN 65. 8% Non HTN 34. 2% Hypertensinwas diagnosed in 65. 8 % patients visiting to outpatient clinic Harapan Kita Cardiovascular Center Saifur Rohman et al. unpublished data, 2008 Controlled 39. 3% Uncontrolled 60. 7% Among hypertensive patients only 39. 3% reached blood pressure target of SBP<140 and DBP<90 mm. Hg

Blood Pressure Target Achievement in dr. Saiful Anwar Hospital 2011 2012 Optimized antihypertensive drug and Education for Compliance Mifetika Lukitasari et al. ASMIHA abstract book, 2012 Saifur Rohman et al. Asean Heart Journal 2011; 19: 20 -23 Mifetika Lukitasari et al. INASH abstract book, 2013

BP in AMI pts on EDAdmission : Awareness SBP<140 and DBP<90 Number of Patient SBP≥ 140 and DBP≥ 90 Unaware of HT Aware of HT Saifur Rohman et al. unpublished data, 2010

Consequences Structural Changes in Hypertension Loss of buffering Function Increased blood pressure Structural changes in compliance arteries Transmits Systolic pressure Wave to small arteries Compliance Shear stress on Artery wall Endothelial dysfunction Load on heart Perpetuation of Hypertension Left Ventricular Hypertrophy Dzau VJ. Hypertension. 2001; 37: 1047 -1052 Predisposes of Atherosclerosis

The Progression from Hypertension to Heart Failure LVH Diastolic dysfunction Hypertension CHF Systolic dysfunction MI LV Normal LV Structure & Function remodeling Subclinical LV dysfunction Time (decades) Vasan RS, Levy D. 1996. Arch Intern Med 156 : 1759 -1796 Overt Heart Failure Time (months) Death

The Importance of HTN in Development of HF n n n Hypertension (HTN) is present in 91% of patients who develop CHF, tripling the risk of normotensive HTN is a common risk factor of HF, treatable, and often under-treated Hypertension remains the major preventable factor Vasan RS, Levy D. 1996. Arch Intern Med 156 : 1759 -1796

Cumulative Incidence of Heart failure in Normotensive and Hypertensive Patients 20 Stage 2 hypertension 15 CHF Cumulative Incidence 10 (%) Stage 1 hypertension 5 Normal BP 0 5 10 Years From Baseline Exam Lenfant C, Roccella EJ. J Hypertens Suppl. 1999; 17: S 3 -S 7. Data from Levy D et al. JAMA. 1996; 275: 1557 -1562. 15

HF Prevention n n Treat Hypertension Early diagnosis and prompt treatment of MI Adequate treatment of RHD Treat and prevent DM to prevent Cardiomyopathy DM Early diagnosis of Myocarditis to prevent cardiomyoptahy

Adequate and prevent recurrence of RHD n n Recognition of acute rheumatic fever Prompt treatment AB prophylaxis Refer to cardiologist

HF Prevention n n Treat Hypertension Early diagnosis and prompt treatment of MI Adequate treatment of RHD Early diagnosis and refer congenital heart disease Early diagnosis of Myocarditis to prevent cardiomyoptahy

Prevent development of HF in congenital heart disease n n n Early diagnosis Sent to cardiologist at proper time AB prophylaxis

HF Prevention n n Treat Hypertension Early diagnosis and prompt treatment of MI Adequate treatment of RHD Treat and prevent DM to prevent Cardiomyopathy DM Early diagnosis of Myocarditis to prevent cardiomyoptahy

Prevent cardiomyopathy n n n Carditis : Viral, RHD, etc PPCM, SLE Prevent by early diagnosis and prompt treatment

Summary n n High mortality and morbidity of HF Preventable by HF Risk factor intervention, Early diagnosis and prompt treatment