TINJAUAN PUSTAKA
ABSTRACT
Gagal jantung akut merupakan kondisi dengan gejala dan tanda gagal jantung *
Emergency & Trauma Center,
yang terjadi dalam onset cepat, dan disebabkan oleh gangguan fungsi jantung Siloam Hospitals Kebun Jeruk).
baik itu disfungsi sistolik atau diastolic, gangguan katup akut, aritmia maupun **
ketidaksesuaian antara preload dengan afterload. Penyebabnya bisa berasal Departemen Kardiologi dan
dari beragam mekanisme, namun kondisi ini merupakan kegawatdaruratan Vaskular Pusat Jantung Nasional
sehingga penting untuk segera dideteksi dan diberikan terapi yang tepat Harapan Kita/Fakultas Kedokteran
untuk menekan angka mortalitas dan morbiditas. Terdapat 7 profil klinis dari Universitas Indonesia)
sindrom gagal jantung akut; acute decompensated heart failure (ADHF),
edema pulmoner akut, syok kardiogenik, gagal jantung akut pada sindrom
koroner akut, gagal jantung kanan terisolir, gagal jantung high-output dan
gagal jantung hipertensif. Pengenalan profil klinis tersebut akan sangat penting
dalam menentukan terapi yang tepat. Diagnosa dibuat berdasarkan
anamnesa yang cermat, pemeriksaan fisik serta disokong dengan berbagai
pemeriksaan penunjang seperti foto rontgen dada, ekokardiografi dan tes
biomarker di laboratorium. Tujuan utama terapi adalah mengatasi gejala
yang ada dan menstabilkan hemodinamik, terutama menjamin oksigenisasi
serta perfusi jaringan.
Kata kunci: gagal jantung akut, profil klinis, diagnosis, terapi
1. Generally, AHF could be induced by one or a combi- genic shock.5 Data from ESC-HF Pilot Survey8 showed
nation of hemodynamic mechanisms including in- that acute decompensated HF was most frequent pre-
creased afterload due to systemic or pulmonary hy- sentation of AHF (75% of the cases) in clinical setting.
pertension or high output states (septicemia, anemia, The patients presenting with cardiogenic shock have
thyrotoxicosis); increased preload due to volume over- the worst short-term prognosis with the highest in-hos-
load; decreased cardiac contractility due to significant pital mortality rate so that patients presenting with this
infarct or other myopathies; or diastolic dysfunction.5,6 clinical profile should be aggressively treated. Whereas,
Identifying the underlying factor is very crucial in strat- the lowest mortality rate is in those with hypertensive
egy to manage patients with AHF. HF. Furthermore, there are three major independent
determinants of death in AHF, those are low systolic
Table 1. Several precipitating factors of AHF
blood pressure, older age, and reduced renal function.8
† Acute myocarditis
Look into its pathophysiology, there are three phases vicious cycle leading into severe cardiovascular failure
of AHF; Initiation, amplification and final vicious cycle.6 with low cardiac output, hypoxemia, activated neuro-
The disturbance in hemodynamic processes leads to hormonal and inflammatory modulators, vasoconstric-
the genesis of the initial phase of AHF which com- tion, decreased peripheral perfusion, respiratory fail-
prises both backward failure (increased LV filling pres- ure, and if untreated, multi-organ failure and death.
sure lading to pulmonary congestion) and forward fail-
The clinical presentation of AHF reflects a spectrum of
ure (peripheral hypoperfusion). This phase is marked
conditions. Some classifications have been applied in
as acute diastolic dysfunction on echocardiography.
order to giving guide how to manage every distinct pre-
Once initiated, AHF is amplified through several mecha-
sentation of AHF and also to predict prognosis of the
nisms; myocardial necrosis as measured by troponin
patients. The patients with AHF will usually present in
release (PRESERVD-HF study), respiratory failure and
one of 7 clinical categories; worsening or acute dec-
leakage of the alveolar-capillary membrane, RV fail-
ompensated chronic HF, pulmonary oedema, hyper-
ure, renal failure, and arrhythmias especially atrial
tensive heart failure, high output failure, AHF in acute
tachyarrhythmias which is a strong predictor of recur-
coronary syndrome, isolated RV failure, and cardio-
rent events and death.7 Finally the patients fall into
heart sound is another classical finding by cardiac the evaluation of the functional and structural changes
auscultation of AHF patients, related to low ventricular underlying or associated with AHF. All patients with
compliance or increase ventricular filling pressure. AHF should be evaluated as soon as possible.5
Because this extra sound is low pitch, using the bell of
stethoscope with patient slight left lateral decubitus MANAGING PATIENTS WITH ACUTE HEART
will ease to find this.11 Elevated jugular venous pres- FAILURE SYNDROME
sure (JVP) is perhaps the most useful clinical finding The immediate goals of treatment in AHF are to im-
for detecting AHF especially in decompensated chronic prove symptoms and to stabilize haemodynamic con-
HF setting, associated with elevated pulmonary capil- dition especially oxygenation and tissue perfusion.5
lary wedge pressure (PCWP).6 Abdomino-jugular re- Planning follow up strategy is needed in hospitalized
flux as result of applying midabdominal pressure for 10 patients and also long-term management if the acute
seconds or more also suggests an elevated PCWP.11 episode leads to chronic HF. Initial treatment in AHF
It is important to be noted that although both third heart can be seen at Figure 2. Oxygen therapy and relieving
sound and increased JVP are very specific for detect- patients' distress are the initial treatment at admis-
ing AHF (> 90%), these signs are not sensitive in many sion. Non-invasive ventilation with positive pressure
cases (< 40%).12 Hepatomegaly, ascites and bilateral (NIPPV) is recommended as soon as possible in ev-
pretibial-pedal pitting oedema are easily found, accom- ery patients with respiratory distress caused by acute
panying elevated JVP in decompensated chronic HF pulmonary oedema, but this respiratory assist should
patients. Cool clammy periphery along with low sys- be used with caution in cardiogenic shock as
tolic blood pressure and rapid-weak pulse suggest low haemodynamic compromises would worsen. Intuba-
perfusion. Arrhythmias detected by cardiac ausculta- tion and mechanical ventilation should be restricted to
tion or pulse palpation are not uncommon.6 patients who is failed with NIPPV or with increased
Some confirmatory investigations are needed in mak- respiratory failure or exhaustion as assessed by hy-
ing diagnosis of AHF. Chest X-ray should be performed percapnia.5
as soon as possible at admission for all patients with A specific treatment strategy should be based on dis-
AHF to assess the degree of pulmonary congestion tinguishing the clinical conditions. In acute decompen-
and to differentiate from other pulmonary or cardiac sated HF condition, vasodilators along with loop di-
pathologies. Arterial blood gas analysis usually shows uretics are recommended. Higher dose of diuretics is
hypoxemia with metabolic acidosis. Pulse oximetry usually needed. Morphine is usually indicated in pa-
can be used for practical reason, but it does not pro- tients with pulmonary oedema, along with loop diuret-
vide information about pCO2 or acid-base status.5 ics and vasodilators. Lowering blood pressure with ti-
Natriuretic peptides (BNP and NT-proBNP) are very trated vasodilators simply improve symptoms of pa-
useful in determining diagnosis and prognosis of pa- tients with hypertensive HF. Fluid resuscitation is sug-
tients with AHF. Increased natriuretic peptides value gested along with inotropic agents to support patients
has a negative predictive value for ruling out HF. Gen- with right HF. Patients with cardiogenic shock need
erally, BNP cutoff 100 pg/mL can be used to rule out more aggressive therapy including fluid challenge in
HF and cutoff 400 pg/mL to rule in HF. The higher BNP small amount (250 mL) followed by an inotrope. An
value, the worse prognosis of patients, so that more Intra-Aortic Balloon Pump (IABP) and intubation should
aggressive therapy should be made for these patients.13 be considered.5,6 Selecting agents according to sys-
Echocardiography with Doppler is an essential tool for tolic blood pressure can be seen at Figure 3.
Patient distressed or in pain
> YES > Analgesia, sedation (morphine)
SaO2 < 95% > YES > Increase Fi02; consider NIPPV;
mechanical ventilation
NIPPV = Non-Invasive Positive Pressure Ventilator (adapted from ESC Guidelines for the diag-
nosis and treatment of acute and chronic heart failure.
SBP > 100 mmHg SBP - 100 mmHg SBP < 100 mmHg